Provider Demographics
NPI:1831261783
Name:LIM, EDMON WANG (MD)
Entity type:Individual
Prefix:DR
First Name:EDMON
Middle Name:WANG
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 1:4614 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5627
Mailing Address - Country:US
Mailing Address - Phone:703-385-1813
Mailing Address - Fax:703-385-4505
Practice Address - Street 1:MOUNT VERNON HOSPITAL
Practice Address - Street 2:2501 PARKERS LANE
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306
Practice Address - Country:US
Practice Address - Phone:703-855-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035379207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5806461Medicaid
VAD09628Medicare UPIN
VA5806461Medicaid