Provider Demographics
NPI:1063083798
Name:JIMENEZ, EUSEBIO R
Entity type:Individual
Prefix:
First Name:EUSEBIO
Middle Name:R
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 SW 165TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3302
Mailing Address - Country:US
Mailing Address - Phone:702-606-9651
Mailing Address - Fax:
Practice Address - Street 1:4385 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7628
Practice Address - Country:US
Practice Address - Phone:305-824-0637
Practice Address - Fax:305-824-0628
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-04
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11014051363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty