Healthcare Provider Details

I. General information

NPI: 1518525435
Provider Name (Legal Business Name): JUSTIN J SO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-8358
US

V. Phone/Fax

Practice location:
  • Phone: 818-636-9346
  • Fax:
Mailing address:
  • Phone: 818-636-9346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA200848
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA200848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: