Provider Demographics
NPI:1982605259
Name:SONG, ANGIE U (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:U
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 1:3655 EVERGREEN PT RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:WA
Mailing Address - Zip Code:98039
Mailing Address - Country:US
Mailing Address - Phone:425-324-6144
Mailing Address - Fax:425-455-0045
Practice Address - Street 1:1225 N H ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-3301
Practice Address - Country:US
Practice Address - Phone:805-737-8700
Practice Address - Fax:805-737-8649
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60136134207YX0905X
CAG84700207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174028401Medicaid
TX8S2230OtherBCBS
TX8D5299Medicare PIN
TX174028401Medicaid