Provider Demographics
NPI:1922130541
Name:SONG, MYUNG AE (DO , MBA)
Entity Type:Individual
Prefix:
First Name:MYUNG
Middle Name:AE
Last Name:SONG
Suffix:
Gender:F
Credentials:DO , MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12706 DEER RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7806
Mailing Address - Country:US
Mailing Address - Phone:208-901-5144
Mailing Address - Fax:
Practice Address - Street 1:8950 W EMERALD ST
Practice Address - Street 2:STE 168
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8296
Practice Address - Country:US
Practice Address - Phone:208-901-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-322208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDCS-10302OtherIDAHO CONTROLLED SUBSTANC
IDH06991OtherUPIN #
IDO-322OtherIDAHO MEDICAL LICENSE
IDBS5805342OtherDEA #