Provider Demographics
NPI:1336292994
Name:LIM, MABEL AUDREY (MD)
Entity Type:Individual
Prefix:DR
First Name:MABEL
Middle Name:AUDREY
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 1:638 WEBSTER ST # 450
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-4168
Mailing Address - Country:US
Mailing Address - Phone:510-832-8819
Mailing Address - Fax:510-835-4051
Practice Address - Street 1:638 WEBSTER ST # 450
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4168
Practice Address - Country:US
Practice Address - Phone:510-832-8819
Practice Address - Fax:510-835-4051
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48096208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A480960Medicaid
CA1336292994Medicare NSC
CA00A480960Medicare ID - Type Unspecified
CA00A480960Medicaid