Provider Demographics
NPI:1104844216
Name:LIM, MARK B (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:LIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5253
Mailing Address - Country:US
Mailing Address - Phone:813-685-2191
Mailing Address - Fax:813-689-8755
Practice Address - Street 1:2404 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-2214
Practice Address - Country:US
Practice Address - Phone:863-802-8440
Practice Address - Fax:863-802-8310
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9151225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4516Medicare ID - Type Unspecified
FLP12954Medicare UPIN