Provider Demographics
NPI:1992724926
Name:JIMENEZ, LINA E (MD)
Entity type:Individual
Prefix:
First Name:LINA
Middle Name:E
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 WAWONA STREET
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-5232
Mailing Address - Country:US
Mailing Address - Phone:323-254-8797
Mailing Address - Fax:323-254-6867
Practice Address - Street 1:12445 RUSH ST
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-4145
Practice Address - Country:US
Practice Address - Phone:323-254-8797
Practice Address - Fax:323-254-6867
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29309207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A293090Medicaid
A29309Medicare ID - Type Unspecified
CA00A293090Medicaid