Provider Demographics
NPI:1063404259
Name:LIM, CUSTODIO L (MD)
Entity type:Individual
Prefix:
First Name:CUSTODIO
Middle Name:L
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 1:2235 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-3330
Mailing Address - Country:US
Mailing Address - Phone:812-234-5273
Mailing Address - Fax:812-232-4714
Practice Address - Street 1:2235 WABASH AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-3330
Practice Address - Country:US
Practice Address - Phone:812-234-5273
Practice Address - Fax:812-232-4714
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035522208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251710AMedicaid
IN000000087131OtherBC/BS PROVIDER NO.
INC25922Medicare UPIN
IN856920Medicare ID - Type UnspecifiedMEDICARE PROVIDER NO.