Healthcare Provider Details

I. General information

NPI: 1629069521
Provider Name (Legal Business Name): JOSE A LIMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD STE 183B
ST LOUIS MO
63128
US

IV. Provider business mailing address

10004 KENEELY RD STE 18313
ST LOUIS MO
63128
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-8400
  • Fax: 314-840-8402
Mailing address:
  • Phone: 314-843-8400
  • Fax: 314-843-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberT9744
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: