Provider Demographics
NPI:1043655640
Name:SONG, JIANBO JAMES (PHD)
Entity Type:Individual
Prefix:DR
First Name:JIANBO
Middle Name:JAMES
Last Name:SONG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1405
Mailing Address - Country:US
Mailing Address - Phone:310-869-5572
Mailing Address - Fax:
Practice Address - Street 1:5755 COTTLE RD
Practice Address - Street 2:BUILDING 2 GENETICS
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-3640
Practice Address - Country:US
Practice Address - Phone:408-972-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTO666207SC0300X
CAMTP288207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
No207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics