Provider Demographics
NPI:1083657910
Name:LIM, JAE Y (MD)
Entity Type:Individual
Prefix:DR
First Name:JAE
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 1:1850 TOWN CENTER PKWY STE 559
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-3300
Mailing Address - Country:US
Mailing Address - Phone:703-876-4270
Mailing Address - Fax:703-876-4276
Practice Address - Street 1:1850 TOWN CENTER PKWY STE 559
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3300
Practice Address - Country:US
Practice Address - Phone:703-876-4270
Practice Address - Fax:703-876-4276
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA060129207T00000X
VA0101240401207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
6186-0001OtherCAREFIRST ID
WAGAB21300Medicare ID - Type Unspecified
VAG020406J01Medicare PIN