Provider Demographics
NPI:1033287487
Name:LIM, IVAN Y (MD)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:Y
Last Name:LIM
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 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:700 2ND ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-8100
Practice Address - Country:US
Practice Address - Phone:202-346-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-02
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD45573207R00000X
DCMD20695207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
007183M92Medicare ID - Type Unspecified
P27756Medicare UPIN