Provider Demographics
NPI:1164588125
Name:SONG, FENGJIN (OMD)
Entity Type:Individual
Prefix:
First Name:FENGJIN
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 FLORAVISTA DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-2624
Mailing Address - Country:US
Mailing Address - Phone:281-280-0184
Mailing Address - Fax:
Practice Address - Street 1:10515 BELLAIRE BLVD STE A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-5235
Practice Address - Country:US
Practice Address - Phone:281-561-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC00251171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15770588OtherDRIVE LISCENSE NUMBER