MEDICARE: DR. NINA SONG OD

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	152W00000X	Optometrist	34312TLG	CA

General Provider Information

NPI Number	:	1790335610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NINA SONG OD

Provider Business Mailing Address
First Line	:	1640 CAMINO DEL RIO N STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1523
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 CAMINO DEL RIO N STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1523
Country	:	US
Telephone Number	:	619-299-4888
Fax Number	:

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

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	12/11/2019

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