Basic Information
| Provider Information | |||||||||
| NPI: | 1003011339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | LINCOLN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2130 E JOHNSON AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504946003 | ||||||||
| FaxNumber: | 8504949636 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 E JOHNSON AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504946003 | ||||||||
| FaxNumber: | 8504949636 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MD61014044 | WA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | ME116162 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0225733 | 05 | OH | MEDICAID | 7100471960 | 05 | KY | MEDICAID | 1003011339 | 05 | WA | MEDICAID |