Provider Demographics
NPI:1114196276
Name:SONG, DONGKYU (LAC DAOM)
Entity Type:Individual
Prefix:
First Name:DONGKYU
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:LAC DAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-3109
Mailing Address - Country:US
Mailing Address - Phone:302-482-3025
Mailing Address - Fax:302-476-8176
Practice Address - Street 1:249 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-3109
Practice Address - Country:US
Practice Address - Phone:302-482-3025
Practice Address - Fax:302-476-8176
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9686171100000X
PAOM000100171100000X
DECQ-0000023171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist