Provider Demographics
NPI:1639179724
Name:LIM, VICTOR ALLEN (OD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:ALLEN
Last Name:LIM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 KENNEDY PL
Mailing Address - Street 2:STE 1
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-1271
Mailing Address - Country:US
Mailing Address - Phone:530-756-2481
Mailing Address - Fax:530-756-3548
Practice Address - Street 1:1109 KENNEDY PL
Practice Address - Street 2:STE 1
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-1271
Practice Address - Country:US
Practice Address - Phone:530-756-2481
Practice Address - Fax:530-756-3548
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5175152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49118YMedicaid
T09894Medicare UPIN
CASD0051750Medicare ID - Type Unspecified