Provider Demographics
NPI:1699761940
Name:JIMENEZ, DOMINGO D (MD)
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:D
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-770-0025
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33 MITCHELL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1674
Practice Address - Country:US
Practice Address - Phone:607-762-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1894241207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01610879Medicaid
NYBB4163Medicare PIN
F31190Medicare UPIN