Provider Demographics
NPI:1073504262
Name:LIM, DERRICK GUY (OD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:GUY
Last Name:LIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5649 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4710
Mailing Address - Country:US
Mailing Address - Phone:562-422-3378
Mailing Address - Fax:909-869-9354
Practice Address - Street 1:5649 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4710
Practice Address - Country:US
Practice Address - Phone:562-422-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10509TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0105090Medicaid
U65908Medicare UPIN
CASD0105090Medicaid
CAWOP10509AMedicare PIN