Provider Demographics
NPI:1013945864
Name:LIM, ROSEMARIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSEMARIE
Middle Name:L
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ROSEMARIE
Other - Middle Name:L
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:228 SOUTHPARK CIR E
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5135
Mailing Address - Country:US
Mailing Address - Phone:904-824-6266
Mailing Address - Fax:904-826-3244
Practice Address - Street 1:228 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5135
Practice Address - Country:US
Practice Address - Phone:904-824-6266
Practice Address - Fax:904-826-3244
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69952207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35425OtherBLUE CROSS BLUE SHIELD
FLH18549Medicare UPIN