Provider Demographics
NPI:1366515942
Name:LIM, MYOZA THERESA (MD)
Entity type:Individual
Prefix:
First Name:MYOZA
Middle Name:THERESA
Last Name:LIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3030 W OLYMPIC BLVD
Mailing Address - Street 2:#206
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-6501
Mailing Address - Country:US
Mailing Address - Phone:213-739-8610
Mailing Address - Fax:213-739-5771
Practice Address - Street 1:3030 W OLYMPIC BLVD
Practice Address - Street 2:#206
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-6501
Practice Address - Country:US
Practice Address - Phone:213-739-8610
Practice Address - Fax:213-739-5771
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA36593208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A365930Medicaid
CA00A365930Medicaid
B50329Medicare UPIN