Basic Information
| Provider Information | |||||||||
| NPI: | 1629210505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | YEON | ||||||||
| MiddleName: | KYUNG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SONG | ||||||||
| OtherFirstName: | YEON | ||||||||
| OtherMiddleName: | KYUNG | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025783270 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2716 N TENAYA WAY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | P9967 | TX | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 17071 | NV | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629210505 | 01 | NV | SMA MEDICAID | OTHER |