Provider Demographics
NPI:1891788725
Name:SONG, DIANE JUNGYUN (OD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:JUNGYUN
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 1:26926 THE OLD RD
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91381-0662
Mailing Address - Country:US
Mailing Address - Phone:661-310-3445
Mailing Address - Fax:661-310-1999
Practice Address - Street 1:26926 THE OLD RD
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91381-0662
Practice Address - Country:US
Practice Address - Phone:661-310-3445
Practice Address - Fax:661-310-1999
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11750T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117500Medicaid
V03073Medicare UPIN
CAOP11750Medicare ID - Type Unspecified