Provider Demographics
NPI:1548536972
Name:SONG, EIN GUN (MD)
Entity type:Individual
Prefix:DR
First Name:EIN
Middle Name:GUN
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15906 MILL CREEK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1797
Mailing Address - Country:US
Mailing Address - Phone:425-385-2009
Mailing Address - Fax:
Practice Address - Street 1:15906 MILL CREEK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1797
Practice Address - Country:US
Practice Address - Phone:425-385-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127623207N00000X
WA60604630207N00000X
WAMD60604630207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology