Provider Demographics
NPI:1487337796
Name:JIMENEZ PEREZ, DIEGO AXEL
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:AXEL
Last Name:JIMENEZ PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DIEGO
Other - Middle Name:
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1940 E DEERE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1940 E DEERE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5718
Practice Address - Country:US
Practice Address - Phone:714-543-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-11
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker