Healthcare Provider Details

I. General information

NPI: 1144665423
Provider Name (Legal Business Name): MIHAE SONG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 11/27/2023
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DUARTE RD
DUARTE CA
91010-3012
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 626-256-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA09284600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number59023
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberC170610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: