Provider Demographics
NPI:1548379696
Name:LIM, JOSE AUDIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:AUDIE
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 1:1209 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5601
Mailing Address - Country:US
Mailing Address - Phone:940-767-5111
Mailing Address - Fax:940-767-5011
Practice Address - Street 1:1209 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5601
Practice Address - Country:US
Practice Address - Phone:940-767-5111
Practice Address - Fax:940-767-5011
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4486207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124017805Medicaid
TX0035KLOtherBCBS
TX8A9829Medicare ID - Type Unspecified
TX0035KLOtherBCBS