Provider Demographics
NPI:1689757049
Name:LIM, JUNG J (DO)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:J
Last Name:LIM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 MEDICAL PLAZA DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2867
Mailing Address - Country:US
Mailing Address - Phone:916-784-1836
Mailing Address - Fax:916-784-1880
Practice Address - Street 1:5 MEDICAL PLAZA DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2867
Practice Address - Country:US
Practice Address - Phone:916-784-1836
Practice Address - Fax:916-784-1880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20A87672086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX87670Medicaid
CA020A87672Medicare PIN
CA020A87671Medicare PIN
CA020A87670Medicare PIN
CA00AX87670Medicaid