Basic Information
Provider Information | |||||||||
NPI: | 1962760348 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MORALES JIMENEZ | ||||||||
FirstName: | MARIELA | ||||||||
MiddleName: | JOSE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 SEYMOUR STREET | ||||||||
Address2: | HARTFORD HOSPITAL MEDICINE DEPT | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061028000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609720200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 132 JEFFERSON STREET | ||||||||
Address2: | HARTFORD HOSPITAL MEDICINE DEPT | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061062429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609720200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/24/2012 | ||||||||
LastUpdateDate: | 06/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10044079 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD60511574 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 067074 | CT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.