Provider Demographics
NPI:1093714362
Name:SONG, KUM (MD)
Entity Type:Individual
Prefix:DR
First Name:KUM
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 1:13904 LAKESHORE BLVD
Mailing Address - Street 2:STE 410
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1481
Mailing Address - Country:US
Mailing Address - Phone:727-862-5489
Mailing Address - Fax:727-862-0397
Practice Address - Street 1:13904 LAKESHORE BLVD
Practice Address - Street 2:STE 410
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1481
Practice Address - Country:US
Practice Address - Phone:727-862-5489
Practice Address - Fax:727-862-0397
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00486602085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL063864100Medicaid
FL063864100Medicaid
C59257Medicare UPIN