Provider Demographics
NPI:1992757355
Name:JIMENEZ, JESUS RAUL
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:RAUL
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:J. RAUL
Other - Middle Name:
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2311 N MESA BUILD I
Mailing Address - Street 2:2311 N MESA BUILD I
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-2310
Mailing Address - Country:US
Mailing Address - Phone:915-544-0600
Mailing Address - Fax:915-544-5374
Practice Address - Street 1:2311 N MESA BUILD I
Practice Address - Street 2:2311 N MESA BUILD I
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3575
Practice Address - Country:US
Practice Address - Phone:915-544-0600
Practice Address - Fax:915-544-5374
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1112193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83134901Medicaid
TX83134901Medicaid