Provider Demographics
NPI:1821368390
Name:SONG, XIAOYAN (MD)
Entity Type:Individual
Prefix:
First Name:XIAOYAN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13621 ROOSEVELT AVE STE 409
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5507
Mailing Address - Country:US
Mailing Address - Phone:718-961-1836
Mailing Address - Fax:917-634-2028
Practice Address - Street 1:4199 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3821
Practice Address - Country:US
Practice Address - Phone:718-961-1836
Practice Address - Fax:917-634-2028
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine