Healthcare Provider Details

I. General information

NPI: 1982605259
Provider Name (Legal Business Name): ANGIE U. SONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N H ST
LOMPOC CA
93436-3301
US

IV. Provider business mailing address

3655 EVERGREEN PT RD
MEDINA WA
98039
US

V. Phone/Fax

Practice location:
  • Phone: 805-737-8700
  • Fax: 805-737-8649
Mailing address:
  • Phone: 425-324-6144
  • Fax: 425-455-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number60136134
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberG84700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: