Provider Demographics
NPI:1558405878
Name:LIM, RODRIGO R (MD)
Entity Type:Individual
Prefix:DR
First Name:RODRIGO
Middle Name:R
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 1:506 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1906
Mailing Address - Country:US
Mailing Address - Phone:541-663-3138
Mailing Address - Fax:
Practice Address - Street 1:506 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1906
Practice Address - Country:US
Practice Address - Phone:541-663-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJM571682084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
742949Medicare ID - Type Unspecified
F55890Medicare UPIN