Provider Demographics
NPI:1134374911
Name:ROXAS, JENNIFER SONG (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SONG
Last Name:ROXAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93942-0487
Mailing Address - Country:US
Mailing Address - Phone:847-331-7780
Mailing Address - Fax:
Practice Address - Street 1:23625 HOLMAN HWY
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5902
Practice Address - Country:US
Practice Address - Phone:847-331-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122345207L00000X
IL036.128733207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGW748ZMedicare PIN