Provider Demographics
NPI:1922015056
Name:SONGVILAY, NOKEO (DO)
Entity Type:Individual
Prefix:DR
First Name:NOKEO
Middle Name:
Last Name:SONGVILAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 ROBINSON AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-7633
Mailing Address - Country:US
Mailing Address - Phone:619-692-9331
Mailing Address - Fax:619-692-9403
Practice Address - Street 1:1807 ROBINSON AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-7633
Practice Address - Country:US
Practice Address - Phone:619-692-9331
Practice Address - Fax:619-692-9403
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX66390Medicaid
CAG30295Medicare UPIN
CA20A6639Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER