Provider Demographics
NPI:1679705974
Name:LIM, KENNETH JOHN G (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH JOHN
Middle Name:G
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:12780 WATERFORD LAKES PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-4501
Mailing Address - Country:US
Mailing Address - Phone:407-384-1053
Mailing Address - Fax:407-277-8168
Practice Address - Street 1:12780 WATERFORD LAKES PKWY STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4501
Practice Address - Country:US
Practice Address - Phone:407-384-1053
Practice Address - Fax:407-277-8168
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01071118A207Q00000X
FLME139409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201072690Medicaid
IN201072690Medicaid