Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | DN11703 | FL |
Y | 213EG0000X | General Practice | DN11703 | FL |
NPI | 1003238650 |
---|---|
Provider Name | Isse Song |
First Address | Orlando, FL 32837-4004 |
Second Address | Orlando, FL 32837-4004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/01/2014 |
Last Update Date | 16/01/2014 |