Basic Information
| Provider Information | |||||||||
| NPI: | 1275529356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIM | ||||||||
| FirstName: | VICENTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 VILLAGE GREEN CT | ||||||||
| Address2: | |||||||||
| City: | SOUTH ORANGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070791507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 COX ST | ||||||||
| Address2: | |||||||||
| City: | ROSELLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 072031703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082417200 | ||||||||
| FaxNumber: | 9082412025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 25MA05886500 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 6204406 | 05 | NJ | MEDICAID |