1134161615 NPI number — MITZI T JIMINEZ MD

Table of content: (NPI 1134161615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134161615 NPI number — MITZI T JIMINEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MITZI T JIMINEZ MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1134161615
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 231233
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77223-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-923-6333
Provider Business Mailing Address Fax Number:
713-923-4197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 S WAYSIDE DR
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77023-3428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-923-6333
Provider Business Practice Location Address Fax Number:
713-923-4197
Provider Enumeration Date:
06/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JIMENEZ
Authorized Official First Name:
MITZI
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
713-923-6333

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F6790 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 123701806 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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