Provider Demographics
NPI:1649266826
Name:SONG, GRACE EUN-KYENG (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:EUN-KYENG
Last Name:SONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:EUN-KYENG
Other - Last Name:JIH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11555 1/2 POTRERO RD
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6946
Mailing Address - Country:US
Mailing Address - Phone:951-849-4761
Mailing Address - Fax:951-922-8436
Practice Address - Street 1:11555 1/2 POTRERO RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6946
Practice Address - Country:US
Practice Address - Phone:951-849-4761
Practice Address - Fax:951-922-8436
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH37043Medicare UPIN