Provider Demographics
NPI:1346717675
Name:SONG, JUSTIN SEUNGBAE
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:SEUNGBAE
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6717 KINGS HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-4619
Mailing Address - Country:US
Mailing Address - Phone:310-991-9859
Mailing Address - Fax:
Practice Address - Street 1:2499 S WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5434
Practice Address - Country:US
Practice Address - Phone:310-638-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant