MEDICARE: DR. JIANBO JAMES SONG PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SC0300X	Clinical Cytogenetics Physician	MTO666	CA
2	207SG0203X	Clinical Molecular Genetics Physician	MTP288	CA

General Provider Information

NPI Number	:	1043655640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIANBO JAMES SONG PHD

Provider Business Mailing Address
First Line	:	3145 PURDUE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-1405
Country	:	US
Telephone Number	:	310-869-5572
Fax Number	:

Provider Business Practice Location Address
First Line	:	5755 COTTLE RD
Second Line	:	BUILDING 2 GENETICS
City	:	SAN JOSE
State	:	CA
Zip	:	95123-3640
Country	:	US
Telephone Number	:	408-972-3330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2013
Last Update Date	:	05/08/2013

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