Provider Demographics
NPI:1821082090
Name:LIM, JOSE DENNIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:DENNIS
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69925 CASSOPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9210
Mailing Address - Country:US
Mailing Address - Phone:574-339-7455
Mailing Address - Fax:
Practice Address - Street 1:1901 W WESTERN AVE
Practice Address - Street 2:#B
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-3521
Practice Address - Country:US
Practice Address - Phone:574-234-9033
Practice Address - Fax:574-234-9059
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044250A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200074220Medicaid
INF93095Medicare UPIN
IN200074220Medicaid