Provider Demographics
NPI:1063502375
Name:SONG, HANJOON MIKE (MD)
Entity Type:Individual
Prefix:DR
First Name:HANJOON
Middle Name:MIKE
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3096 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:770-495-1477
Mailing Address - Fax:770-495-1488
Practice Address - Street 1:3096 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:770-495-1477
Practice Address - Fax:770-495-1488
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2015-08-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA057679208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA762679427BMedicaid