Provider Demographics
NPI:1871609404
Name:JIMENEZ, ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:
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 1:1499 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3255
Mailing Address - Country:US
Mailing Address - Phone:310-831-9482
Mailing Address - Fax:310-832-0994
Practice Address - Street 1:1294 W 6TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2987
Practice Address - Country:US
Practice Address - Phone:310-831-9482
Practice Address - Fax:310-831-1230
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G552500Medicaid
A93357Medicare UPIN
WG55250CMedicare ID - Type UnspecifiedMEDICARE PART B PPIN