Provider Demographics
NPI:1629172168
Name:LIM, GREGORIO TRINIDAD (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORIO
Middle Name:TRINIDAD
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4254 POINT LA VISTA RD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6248
Mailing Address - Country:US
Mailing Address - Phone:904-259-6211
Mailing Address - Fax:904-259-7103
Practice Address - Street 1:7487 S STATE ROAD 121
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-5451
Practice Address - Country:US
Practice Address - Phone:904-259-6211
Practice Address - Fax:904-259-7104
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 19920207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53092Medicare UPIN
FL16916Medicare ID - Type Unspecified