1194846923 NPI number — DR. DEREK JIMENEZ M.D.

Table of content: DR. DEREK JIMENEZ M.D. (NPI 1194846923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194846923 NPI number — DR. DEREK JIMENEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JIMENEZ
Provider First Name:
DEREK
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194846923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11037
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32524-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-444-7000
Provider Business Mailing Address Fax Number:
850-444-7497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 CREIGHTON RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-7152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-444-4700
Provider Business Practice Location Address Fax Number:
850-434-8144
Provider Enumeration Date:
04/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RN0300X , with the licence number:  MD.30541 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: ME97915 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 278621400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD.30541 . This is a "ALABAMA MEDICAL LICENSURE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: ME97915 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 278621400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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