Provider Demographics
NPI:1093730301
Name:LIM, CYNTHIA (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:
Other - Last Name:CONCEPCION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1646 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2405
Mailing Address - Country:US
Mailing Address - Phone:707-645-8576
Mailing Address - Fax:
Practice Address - Street 1:1646 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2405
Practice Address - Country:US
Practice Address - Phone:707-645-8576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73071208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730710Medicaid
CA00A730710Medicaid
CAH25775Medicare UPIN
CA00A730710Medicare ID - Type UnspecifiedMEDICARE ID#