Provider Demographics
NPI:1811072028
Name:SONG, RICHARD (OD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JEONG-HUN
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 394
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98009-0394
Mailing Address - Country:US
Mailing Address - Phone:425-644-6478
Mailing Address - Fax:425-644-6476
Practice Address - Street 1:17 148TH AVE SE
Practice Address - Street 2:STE A
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007
Practice Address - Country:US
Practice Address - Phone:425-644-6478
Practice Address - Fax:425-644-6476
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00004160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00312106OtherRAILROAD MEDICARE
WA2033843Medicaid
WA8871069Medicare PIN
WA2033843Medicaid