Provider Demographics
NPI:1831173970
Name:LIM, RUSSELL F (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1629 JONES ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-4303
Mailing Address - Country:US
Mailing Address - Phone:530-400-7261
Mailing Address - Fax:
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4284
Practice Address - Country:US
Practice Address - Phone:310-627-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG724272084P0800X
CAG0724272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA006724270Medicaid