Provider Demographics
NPI:1194874198
Name:JIMENEZ RIVEROS, RAFAEL M (MD)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:M
Last Name:JIMENEZ RIVEROS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RAFAEL
Other - Middle Name:MAURICIO
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-6831
Practice Address - Fax:804-628-1132
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012650562085R0202X
PAMT1891842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102475239-0001Medicaid
PA179296D2YMedicare PIN