Provider Demographics
NPI:1790770352
Name:YU, SONG KI (DPM)
Entity Type:Individual
Prefix:DR
First Name:SONG
Middle Name:KI
Last Name:YU
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 BLACK ROCK TPKE
Mailing Address - Street 2:STE 8
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3546
Mailing Address - Country:US
Mailing Address - Phone:203-330-8080
Mailing Address - Fax:203-334-6924
Practice Address - Street 1:1817 BLACK ROCK TPKE
Practice Address - Street 2:STE 8 ADVANCED MEDICAL FOOTCARE
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3546
Practice Address - Country:US
Practice Address - Phone:203-330-8080
Practice Address - Fax:203-334-6924
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000764213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5454010001OtherDME
CT5454010001OtherDME
CT480000917Medicare ID - Type Unspecified
CT5454010001Medicare NSC