Provider Demographics
NPI:1427037720
Name:LIM, THERESA O (MD)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:O
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 1:4199 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-323-4440
Mailing Address - Fax:617-323-7870
Practice Address - Street 1:4199 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-323-4440
Practice Address - Fax:617-323-7870
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA81252207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
65231BMCOtherHARVARD PILGRIM
J16426OtherB C
A21100Medicare ID - Type Unspecified
G24500Medicare UPIN