Provider Demographics
NPI:1124472915
Name:JIMENEZ, SAMUEL SEGUNDO (SA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SEGUNDO
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3909 S MASON R
Mailing Address - Street 2:APT #111
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450
Mailing Address - Country:US
Mailing Address - Phone:786-660-6908
Mailing Address - Fax:
Practice Address - Street 1:3903 S MASON RD
Practice Address - Street 2:APT #111
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7708
Practice Address - Country:US
Practice Address - Phone:786-660-6908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16-180246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant