Provider Demographics
NPI:1972654309
Name:LIM, REYNALDO LC (MD)
Entity Type:Individual
Prefix:DR
First Name:REYNALDO
Middle Name:LC
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 1:6545 RIDGE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34668-6865
Mailing Address - Country:US
Mailing Address - Phone:727-848-8058
Mailing Address - Fax:727-848-0091
Practice Address - Street 1:6545 RIDGE RD STE 2
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668-6865
Practice Address - Country:US
Practice Address - Phone:727-848-8058
Practice Address - Fax:727-848-0091
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49722208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61058Medicare UPIN