Provider Demographics
NPI:1134328735
Name:LIM, KELLIE JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:JANE
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 1:7471 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2457
Mailing Address - Country:US
Mailing Address - Phone:559-436-4500
Mailing Address - Fax:559-436-0500
Practice Address - Street 1:7471 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2457
Practice Address - Country:US
Practice Address - Phone:559-436-4500
Practice Address - Fax:559-436-0500
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106613207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0043790Medicaid
CAZZZ21572ZOtherMEDICARE PTAN
CAZZZ21572ZMedicare PIN