Basic Information
| Provider Information | |||||||||
| NPI: | 1659781912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | FERNANDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S DIXIE DR | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338442844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634211190 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 S DIXIE DR | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338442844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634211190 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18740 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.