Provider Demographics
NPI:1063464386
Name:SONG, SOON-IL (MD)
Entity Type:Individual
Prefix:
First Name:SOON-IL
Middle Name:
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 1:214C LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1208
Mailing Address - Country:US
Mailing Address - Phone:585-423-5800
Mailing Address - Fax:585-423-2890
Practice Address - Street 1:82 HOLLAND ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14605-2131
Practice Address - Country:US
Practice Address - Phone:585-423-5800
Practice Address - Fax:585-423-2890
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260927207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03361960Medicaid
NYJ400305748Medicare PIN