Provider Demographics
NPI:1821149063
Name:SONG, GRACE Y (OD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:Y
Last Name:SONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5413 PINE GLEN RD
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1423
Mailing Address - Country:US
Mailing Address - Phone:917-742-1684
Mailing Address - Fax:
Practice Address - Street 1:24201 VALENCIA BLVD
Practice Address - Street 2:VALENCIA TOWN CENTER
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1861
Practice Address - Country:US
Practice Address - Phone:661-287-9893
Practice Address - Fax:661-287-3831
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12945T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP12945Medicare PIN