Healthcare Provider Details

I. General information

NPI: 1972834158
Provider Name (Legal Business Name): DIANNE AGNES SONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E SPRING ST STE 1
LONG BEACH CA
90806-1625
US

IV. Provider business mailing address

450 E SPRING ST STE 1
LONG BEACH CA
90806-1625
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-0050
  • Fax: 562-933-0078
Mailing address:
  • Phone: 562-933-0050
  • Fax: 562-933-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA110239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: