Basic Information
| Provider Information | |||||||||
| NPI: | 1386688349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIM | ||||||||
| FirstName: | MELINDRES | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633150 | ||||||||
| FaxNumber: | 5419755111 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | LA GRANDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978501248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416633150 | ||||||||
| FaxNumber: | 5419755111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD29069 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MA61225 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6994008 | 05 | NJ | MEDICAID |