Provider Demographics
NPI:1114942265
Name:LIM, CAROLYNE TAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYNE
Middle Name:TAN
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 W LE ROY AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7335
Mailing Address - Country:US
Mailing Address - Phone:626-446-7858
Mailing Address - Fax:
Practice Address - Street 1:12598 CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-3502
Practice Address - Country:US
Practice Address - Phone:909-364-1234
Practice Address - Fax:909-364-1227
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55951208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG59124Medicare UPIN