Provider Demographics
NPI:1003278425
Name:SONG, SORA (MD)
Entity type:Individual
Prefix:
First Name:SORA
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 1:3201 S MARYLAND PKWY STE 608
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2428
Mailing Address - Country:US
Mailing Address - Phone:702-457-5437
Mailing Address - Fax:702-464-5801
Practice Address - Street 1:3201 S MARYLAND PKWY STE 608
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2428
Practice Address - Country:US
Practice Address - Phone:702-457-5437
Practice Address - Fax:702-464-5801
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA152715208000000X
NV21284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics