Provider Demographics
NPI:1972834158
Name:SONG, DIANNE AGNES (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:AGNES
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:450 E SPRING ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1625
Mailing Address - Country:US
Mailing Address - Phone:562-933-0050
Mailing Address - Fax:562-933-0078
Practice Address - Street 1:450 E SPRING ST STE 1
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1625
Practice Address - Country:US
Practice Address - Phone:562-933-0050
Practice Address - Fax:562-933-0078
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine