Provider Demographics
NPI:1124028733
Name:LIM, JONATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:LIM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:5575 W LAS POSITAS BLVD
Mailing Address - Street 2:# 130
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-5801
Mailing Address - Country:US
Mailing Address - Phone:925-463-0590
Mailing Address - Fax:925-847-9532
Practice Address - Street 1:5575 W LAS POSITAS BLVD
Practice Address - Street 2:# 130
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-5801
Practice Address - Country:US
Practice Address - Phone:925-463-0590
Practice Address - Fax:925-847-9532
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2012-01-23
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Provider Licenses
StateLicense IDTaxonomies
CAG80939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G809390Medicaid
CA00G809390Medicare ID - Type Unspecified
CA00G809390Medicaid