Provider Demographics
NPI:1801859715
Name:LIM, FRED T (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:T
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:TAI SHIK
Other - Last Name:LIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1801 W OLYMPIC BLVD # 2102
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-0574
Mailing Address - Country:US
Mailing Address - Phone:661-249-6628
Mailing Address - Fax:
Practice Address - Street 1:1420 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2508
Practice Address - Country:US
Practice Address - Phone:818-502-2327
Practice Address - Fax:626-795-4894
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA754032085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A754030Medicaid
CAWA75403CMedicare PIN
CAWA75403AMedicare PIN
CAH42849Medicare UPIN