Provider Demographics
NPI:1689615486
Name:SONGCHAROEN, SOMPRASONG (MD)
Entity Type:Individual
Prefix:
First Name:SOMPRASONG
Middle Name:
Last Name:SONGCHAROEN
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 1:160 FOUNTAINS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6343
Mailing Address - Country:US
Mailing Address - Phone:601-981-2525
Mailing Address - Fax:601-981-3152
Practice Address - Street 1:160 FOUNTAINS BLVD STE B
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-981-2525
Practice Address - Fax:601-981-3152
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07162208200000X, 2082S0099X, 2082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD00809Medicare UPIN