Healthcare Provider Details

I. General information

NPI: 1700292877
Provider Name (Legal Business Name): JAEHA SONG DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3570 S VAL VISTA DR STE 104
GILBERT AZ
85297-7327
US

IV. Provider business mailing address

3570 S VAL VISTA DR STE 104
GILBERT AZ
85297-7327
US

V. Phone/Fax

Practice location:
  • Phone: 480-900-9343
  • Fax: 480-400-9229
Mailing address:
  • Phone: 480-900-9343
  • Fax: 480-400-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD-000896
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC006500
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number65P97423
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPOD-000896
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: