Healthcare Provider Details

I. General information

NPI: 1255080339
Provider Name (Legal Business Name): CANDICE EUNYOUNG SONG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 GLENN MITCHELL DR STE 310
VIRGINIA BEACH VA
23456-0019
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-507-0255
  • Fax: 757-507-0256
Mailing address:
  • Phone: 757-668-7249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102209370
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: