Provider Demographics
NPI:1225353766
Name:JIMENEZ, MARIO ALBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ALBERTO
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 1:12901 SW 66TH TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-1315
Mailing Address - Country:US
Mailing Address - Phone:305-388-1118
Mailing Address - Fax:
Practice Address - Street 1:14740 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33185-5948
Practice Address - Country:US
Practice Address - Phone:305-388-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-27
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME114414208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022441000Medicaid
FLME114414OtherMEDICAL DOCTOR