Provider Demographics
NPI:1790861797
Name:LIM, KIM L (OD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:L
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 1:1126 W US HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-4337
Mailing Address - Country:US
Mailing Address - Phone:956-399-1500
Mailing Address - Fax:956-399-1500
Practice Address - Street 1:1126 W HWY 77
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-4337
Practice Address - Country:US
Practice Address - Phone:956-399-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3660152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0933558802Medicaid
TX0933558802Medicaid
TXT14419Medicare UPIN