Provider Demographics
NPI:1164676490
Name:SOP SONG, OD PC
Entity Type:Organization
Organization Name:SOP SONG, OD PC
Other - Org Name:GALLERIA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOP
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-658-7040
Mailing Address - Street 1:7700 LITTLE RIVER TPKE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2406
Mailing Address - Country:US
Mailing Address - Phone:703-658-7070
Mailing Address - Fax:703-658-7071
Practice Address - Street 1:7700 LITTLE RIVER TPKE
Practice Address - Street 2:SUITE 101
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2406
Practice Address - Country:US
Practice Address - Phone:703-658-7070
Practice Address - Fax:703-658-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618000574OtherSTATE BOARD
MDTA1227OtherSTATE BOARD
VA952788Medicare PIN