Healthcare Provider Details

I. General information

NPI: 1063825792
Provider Name (Legal Business Name): SANGJIN LIM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2014
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 BAY AVE STE 102
GLEN RIDGE NJ
07028-1621
US

IV. Provider business mailing address

311 BAY AVE STE 102
GLEN RIDGE NJ
07028-1621
US

V. Phone/Fax

Practice location:
  • Phone: 973-798-4777
  • Fax: 973-680-7857
Mailing address:
  • Phone: 973-798-4777
  • Fax: 973-680-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB11870000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number25MB11870000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: