Provider Demographics
NPI:1386089423
Name:SONG, MICHELLE MING (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MING
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 1:1502 BROADWAY UNIT 212
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2320
Mailing Address - Country:US
Mailing Address - Phone:281-222-8332
Mailing Address - Fax:
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 380
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2179
Practice Address - Country:US
Practice Address - Phone:281-222-8332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10046312207V00000X
TXR3757207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology