Provider Demographics
NPI:1003376062
Name:SONG, JOONGYU DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:JOONGYU
Middle Name:DANIEL
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 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036166237208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics