Provider Demographics
NPI:1710266770
Name:SONG, STARR ANGELINE
Entity Type:Individual
Prefix:MRS
First Name:STARR
Middle Name:ANGELINE
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2819 EMBASSY ROW
Mailing Address - Street 2:819
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-2988
Mailing Address - Country:US
Mailing Address - Phone:317-400-7545
Mailing Address - Fax:
Practice Address - Street 1:2819 EMBASSY ROW
Practice Address - Street 2:819
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224
Practice Address - Country:US
Practice Address - Phone:317-400-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2350-43-7769171W00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171W00000XOther Service ProvidersContractor