Provider Demographics
NPI:1396213971
Name:LIM, KIRTNEY SO (IDC)
Entity Type:Individual
Prefix:MR
First Name:KIRTNEY
Middle Name:SO
Last Name:LIM
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47149 BUSE RD
Mailing Address - Street 2:
Mailing Address - City:PATUXENT RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:20670-1540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47149 BUSE RD
Practice Address - Street 2:
Practice Address - City:PATUXENT RIVER
Practice Address - State:MD
Practice Address - Zip Code:20670-1540
Practice Address - Country:US
Practice Address - Phone:619-642-4871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman