Provider Demographics
NPI:1649338195
Name:LIM, DOO TAEK (OMD)
Entity type:Individual
Prefix:DR
First Name:DOO TAEK
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3108
Mailing Address - Country:US
Mailing Address - Phone:323-733-9911
Mailing Address - Fax:323-733-9914
Practice Address - Street 1:1234 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3108
Practice Address - Country:US
Practice Address - Phone:323-733-9911
Practice Address - Fax:323-733-9914
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC0021890171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC0021890Medicaid