Provider Demographics
NPI:1235450479
Name:LIM, ILYA (MD)
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:LIM
Suffix:
Gender:M
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:PO BOX 15853
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-1853
Mailing Address - Country:US
Mailing Address - Phone:941-559-7999
Mailing Address - Fax:
Practice Address - Street 1:1617 S TUTTLE AVE FL 3
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3132
Practice Address - Country:US
Practice Address - Phone:941-559-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD451623207N00000X
CT56827207N00000X
FLME153859207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology