Provider Demographics
NPI:1619464799
Name:LIM, MICHAEL JOSHUA (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSHUA
Last Name:LIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:555 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4904
Mailing Address - Country:US
Mailing Address - Phone:909-982-8846
Mailing Address - Fax:909-206-1097
Practice Address - Street 1:8112 MILLIKEN AVE STE 203
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7473
Practice Address - Country:US
Practice Address - Phone:909-945-3563
Practice Address - Fax:909-945-9450
Is Sole Proprietor?:No
Enumeration Date:2018-04-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34161-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist