Healthcare Provider Details

I. General information

NPI: 1669532842
Provider Name (Legal Business Name): TAIIL TED SONG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11203 BRIDGEPORT WAY SW
LAKEWOOD WA
98499-3002
US

IV. Provider business mailing address

11203 BRIDGEPORT WAY SW
LAKEWOOD WA
98499-3002
US

V. Phone/Fax

Practice location:
  • Phone: 253-589-1380
  • Fax:
Mailing address:
  • Phone: 253-589-1380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberOP00002163
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberE-2006
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberOP00002163
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: