Healthcare Provider Details

I. General information

NPI: 1669500484
Provider Name (Legal Business Name): ELISA HAE-JUNG SONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 EL CAMINO REAL SUITE 101
BELMONT CA
94002-3948
US

IV. Provider business mailing address

1085 HEWITT DR
SAN CARLOS CA
94070-3650
US

V. Phone/Fax

Practice location:
  • Phone: 650-595-5437
  • Fax: 650-595-5438
Mailing address:
  • Phone: 650-654-9345
  • Fax: 650-654-9345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA68766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: