Basic Information
| Provider Information | |||||||||
| NPI: | 1619268463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRANADOS | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5880 S HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLOBE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855019447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284253261 | ||||||||
| FaxNumber: | 9284253859 | ||||||||
| Practice Location | |||||||||
| Address1: | 5880 S HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | GLOBE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855019447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284253261 | ||||||||
| FaxNumber: | 9284253859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2011 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A115118 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1841217866 | 05 | CA | MEDICAID | FHC03884F | 05 | CA | MEDICAID | FHC70593F | 05 | CA | MEDICAID | 1841217866 | 01 | CA | CORPORATE NPI NUMBER | OTHER | FHC71031F | 05 | CA | MEDICAID |