Healthcare Provider Details

I. General information

NPI: 1104844216
Provider Name (Legal Business Name): MARK B LIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 MESQUITE AVE STE B
LAKE HAVASU CITY AZ
86403-5771
US

IV. Provider business mailing address

1840 MESQUITE AVE STE B
LAKE HAVASU CITY AZ
86403-5771
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-8500
  • Fax:
Mailing address:
  • Phone: 928-453-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR81303
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT9151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: