Provider Demographics
NPI:1710178462
Name:SONG, SCOTT (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:6
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6509
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:7702 H MOUNT VERNON PLAZA
Practice Address - Street 2:SPACE 63
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306
Practice Address - Country:US
Practice Address - Phone:703-717-0737
Practice Address - Fax:703-717-0739
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618001652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist