Provider Demographics
NPI:1124475363
Name:LIM, JEAGWAN
Entity type:Individual
Prefix:
First Name:JEAGWAN
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 MAPLE AVE STE 201C
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5167
Mailing Address - Country:US
Mailing Address - Phone:929-398-3120
Mailing Address - Fax:833-985-0130
Practice Address - Street 1:4199 MAIN ST STE 202B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3821
Practice Address - Country:US
Practice Address - Phone:929-398-3120
Practice Address - Fax:833-985-0130
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05027858Medicaid