MEDICARE: DR. SONG KI YU 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	213E00000X	Podiatrist	000764	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5454010001	OTHER	CT	DME

General Provider Information

NPI Number	:	1790770352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SONG KI YU DPM

Provider Business Mailing Address
First Line	:	1817 BLACK ROCK TPKE
Second Line	:	STE 8
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3546
Country	:	US
Telephone Number	:	203-330-8080
Fax Number	:	203-334-6924

Provider Business Practice Location Address
First Line	:	1817 BLACK ROCK TPKE
Second Line	:	STE 8 ADVANCED MEDICAL FOOTCARE
City	:	FAIRFIELD
State	:	CT
Zip	:	06825-3546
Country	:	US
Telephone Number	:	203-330-8080
Fax Number	:	203-334-6924

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

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	03/04/2014

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Directions to “ DR. SONG KI YU DPM” Practice Location

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