Basic Information
Provider Information
NPI: 1003009580
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IDICULA
FirstName: MIMI
MiddleName: SONG
NamePrefix:  
NameSuffix:  
Credential: NP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6161 N STATE HIGHWAY 161
Address2:  
City: IRVING
State: TX
PostalCode: 750382220
CountryCode: US
TelephoneNumber: 9722587499
FaxNumber: 9722570897
Practice Location
Address1: 1717 W UNIVERSITY DR
Address2: #408
City: MCKINNEY
State: TX
PostalCode: 75069
CountryCode: US
TelephoneNumber: 9725482600
FaxNumber: 9725482610
Other Information
ProviderEnumerationDate: 08/20/2007
LastUpdateDate: 08/24/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
111N00000X10049TXN Chiropractic ProvidersChiropractor 
363L00000XAP137449TXY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

ID Information
IDTypeStateIssuerDescription
AP13744901TXNURSE PRACTITIONEROTHER


Home