Healthcare Provider Details

I. General information

NPI: 1154326585
Provider Name (Legal Business Name): DWIGHT PETER LIM TIU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FLORIDA PARK DR N
PALM COAST FL
32137-3852
US

IV. Provider business mailing address

12 FLOYD CT
PALM COAST FL
32137-8301
US

V. Phone/Fax

Practice location:
  • Phone: 904-728-6934
  • Fax: 386-251-0943
Mailing address:
  • Phone: 386-328-5437
  • Fax: 386-447-7348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0075674
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME75674
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: