Healthcare Provider Details

I. General information

NPI: 1629210505
Provider Name (Legal Business Name): YEON KYUNG SONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YEON KYUNG SONG M.D.

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 N TENAYA WAY
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax:
Mailing address:
  • Phone: 702-578-3270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberP9967
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number17071
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: