Provider Demographics
NPI:1679749188
Name:SONG, TAE J (DPM)
Entity type:Individual
Prefix:DR
First Name:TAE
Middle Name:J
Last Name:SONG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 CONTINENTAL ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0839
Mailing Address - Country:US
Mailing Address - Phone:530-241-5335
Mailing Address - Fax:
Practice Address - Street 1:1310 CONTINENTAL ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0839
Practice Address - Country:US
Practice Address - Phone:530-241-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 4773213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery