Provider Demographics
NPI:1841413408
Name:LIM, JIN SOO (MD)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:SOO
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7001 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 170
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:703-468-2205
Mailing Address - Fax:703-468-2216
Practice Address - Street 1:7001 HERITAGE VILLAGE PLZ STE 170
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-468-2205
Practice Address - Fax:703-468-2216
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236105207Y00000X
VA010123615207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010082889Medicaid
VA010082889Medicaid
I11210Medicare UPIN