MEDICARE: DR. JAEHA SONG DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	POD-000896	AZ
2	213E00000X	Podiatrist	SC006500	PA
3	282N00000X	General Acute Care Hospital	65P97423	NY
4	213E00000X	Podiatrist	POD-000896	AZ

General Provider Information

NPI Number	:	1700292877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAEHA SONG DPM

Provider Business Mailing Address
First Line	:	3570 S VAL VISTA DR STE 104
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85297-7327
Country	:	US
Telephone Number	:	480-900-9343
Fax Number	:	480-400-9229

Provider Business Practice Location Address
First Line	:	3570 S VAL VISTA DR STE 104
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85297-7327
Country	:	US
Telephone Number	:	480-900-9343
Fax Number	:	480-400-9229

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

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	06/24/2026

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