Provider Demographics
NPI:1699751776
Name:SON, MONIVIRIN (MD)
Entity type:Individual
Prefix:
First Name:MONIVIRIN
Middle Name:
Last Name:SON
Suffix:
Gender:M
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:PO BOX 743752
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3752
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:972-745-4336
Practice Address - Street 1:10652 S EASTERN AVE
Practice Address - Street 2:STE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4952
Practice Address - Country:US
Practice Address - Phone:702-476-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85627208D00000X
NV11009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice