Provider Demographics
NPI:1235160474
Name:MAO, SONGYAN (MD)
Entity Type:Individual
Prefix:
First Name:SONGYAN
Middle Name:
Last Name:MAO
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 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208
Practice Address - Country:US
Practice Address - Phone:425-316-5150
Practice Address - Fax:425-316-5153
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200864900Medicaid
090199OtherSIHO
KY000000482470OtherANTHEM FOR NICC
KYP00415227OtherRR MEDICARE - NICC
INP00838106OtherRR MEDICARE - NICC
IN200864900Medicaid
IN196290HHHMedicare PIN