Healthcare Provider Details

I. General information

NPI: 1376168344
Provider Name (Legal Business Name): MARY KIRSTYLEIGH ANN REVILLA LIM M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LENOX AVE
NEW YORK NY
10037-1802
US

IV. Provider business mailing address

506 LENOX AVE
NEW YORK NY
10037-1802
US

V. Phone/Fax

Practice location:
  • Phone: 212-939-4019
  • Fax: 212-939-4022
Mailing address:
  • Phone: 212-939-4019
  • Fax: 212-939-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32481901
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: