Provider Demographics
NPI:1669430518
Name:LIM, ROBERT M (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
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 1:1530 BESSIE AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-3080
Mailing Address - Country:US
Mailing Address - Phone:209-833-2393
Mailing Address - Fax:
Practice Address - Street 1:1530 BESSIE AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-833-2393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2275262085R0202X
CAA1025672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2136465Medicaid
MA1669430518Medicare UPIN