Provider Demographics
NPI:1801036686
Name:VICTOR SONGBANDITH LLC
Entity Type:Organization
Organization Name:VICTOR SONGBANDITH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SONGBANDITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-241-4734
Mailing Address - Street 1:3022 TRAWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4329
Mailing Address - Country:US
Mailing Address - Phone:915-241-4734
Mailing Address - Fax:915-855-3311
Practice Address - Street 1:101 NORTH ERMA
Practice Address - Street 2:
Practice Address - City:PRESIDIO
Practice Address - State:TX
Practice Address - Zip Code:79845-0693
Practice Address - Country:US
Practice Address - Phone:432-229-4246
Practice Address - Fax:432-229-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-06
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0612305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213263102OtherMEDICAID PART B
TX673912OtherMEDICARE PART A PTAN
TX213263101OtherMEDICAID PART A
TXTXB161127OtherMEDICARE PART B