Basic Information
| Provider Information | |||||||||
| NPI: | 1518353168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JIMENEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | ALBERTO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938116 | ||||||||
| FaxNumber: | 6142935315 | ||||||||
| Practice Location | |||||||||
| Address1: | 10202 JEFFERSON HWY STE D | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257688833 | ||||||||
| FaxNumber: | 2257694839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2015 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35135633 | OH | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 35135633 | OH | N | 207WX0107X | 325976 | LA | Y |
ID Information
| ID | Type | State | Issuer | Description | 0359466 | 05 | OH | MEDICAID | 2561375 | 05 | LA | MEDICAID |