Healthcare Provider Details

I. General information

NPI: 1366415846
Provider Name (Legal Business Name): MIRAN JOELLE SONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 N 4TH ST
FLAGSTAFF AZ
86004-1816
US

IV. Provider business mailing address

PO BOX 3630
FLAGSTAFF AZ
86003-3630
US

V. Phone/Fax

Practice location:
  • Phone: 928-522-9400
  • Fax: 928-774-4808
Mailing address:
  • Phone: 928-522-9400
  • Fax: 928-774-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number161302
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number49275
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: