Provider Demographics
NPI:1972503241
Name:LIM, JEFFREY J (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:J
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:PO BOX 158
Mailing Address - Street 2:410 NE 12TH STREET
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-0158
Mailing Address - Country:US
Mailing Address - Phone:580-338-5500
Mailing Address - Fax:580-468-4942
Practice Address - Street 1:410 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3655
Practice Address - Country:US
Practice Address - Phone:580-338-5500
Practice Address - Fax:580-468-4942
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2013-09-25
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
OK18750207R00000X
KS31131207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF72495Medicare UPIN