Provider Demographics
NPI:1598850158
Name:CHO, SONG S (MD)
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:S
Last Name:CHO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3224 W OLYMPIC BLVD
Mailing Address - Street 2:#203
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2317
Mailing Address - Country:US
Mailing Address - Phone:323-731-2211
Mailing Address - Fax:323-731-2134
Practice Address - Street 1:3224 W OLYMPIC BLVD
Practice Address - Street 2:#203
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2317
Practice Address - Country:US
Practice Address - Phone:323-731-2211
Practice Address - Fax:323-731-2134
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66800207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G668000Medicaid
CA00G668000OtherBLUE SHIELD
CA00G668000Medicaid
CA00G668000OtherBLUE SHIELD