Provider Demographics
NPI:1104844216
Name:LIM, MARK B (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:B
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 1:1840 MESQUITE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-453-8500
Mailing Address - Fax:
Practice Address - Street 1:1840 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5771
Practice Address - Country:US
Practice Address - Phone:928-453-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9151225100000X
AZR81303390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE4516Medicare ID - Type Unspecified
FLP12954Medicare UPIN