Provider Demographics
NPI:1992925507
Name:SONG, AGATHA
Entity type:Individual
Prefix:DR
First Name:AGATHA
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 NW MULHOLLAND DR
Mailing Address - Street 2:# 156
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1942
Mailing Address - Country:US
Mailing Address - Phone:620-802-1220
Mailing Address - Fax:541-673-0901
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1377
Practice Address - Fax:541-440-1394
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04557700174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF42525Medicare UPIN