Provider Demographics
NPI:1770276750
Name:SONG, ALEXANDER (OD)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10692 CAMINITO DURO
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-2803
Mailing Address - Country:US
Mailing Address - Phone:858-880-5332
Mailing Address - Fax:
Practice Address - Street 1:2653 GATEWAY RD STE 101
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-1758
Practice Address - Country:US
Practice Address - Phone:760-476-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist