Provider Demographics
NPI:1619962131
Name:SONG, MI-KYOUNG (MD)
Entity Type:Individual
Prefix:
First Name:MI-KYOUNG
Middle Name:
Last Name:SONG
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 1:5125 SKYLINE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9413
Mailing Address - Country:US
Mailing Address - Phone:503-361-5400
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9427
Practice Address - Country:US
Practice Address - Phone:503-361-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD207140207WX0107X
CAA55885207W00000X
WA61234058207W00000X
OR207140207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ543050Medicaid
NMNM004260OtherBC BS OF NM
CO50900030Medicaid
NM180040573OtherRRB MEDICARE RAILROAD
NM66411Medicaid
AZ543050Medicaid
CO50900030Medicaid