Provider Demographics
NPI:1366537474
Name:SONG, CHARLENE Y (MD)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:Y
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S VIRGIL AVE
Mailing Address - Street 2:#203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1416
Mailing Address - Country:US
Mailing Address - Phone:213-386-1004
Mailing Address - Fax:213-386-1115
Practice Address - Street 1:520 S VIRGIL AVE
Practice Address - Street 2:#203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-1416
Practice Address - Country:US
Practice Address - Phone:213-386-1004
Practice Address - Fax:213-386-1115
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G65248Medicaid
CAG65248OtherCALIF LICENSE
CAE82798Medicare UPIN
CAG65248OtherCALIF LICENSE