Provider Demographics
NPI:1275563041
Name:SONG, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
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:PO BOX 64474
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4474
Mailing Address - Country:US
Mailing Address - Phone:410-502-5875
Mailing Address - Fax:
Practice Address - Street 1:401 N BROADWAY
Practice Address - Street 2:SUITE 1440
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1146
Practice Address - Country:US
Practice Address - Phone:401-502-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD618662085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD404999300Medicaid
MD233363YFUVMedicare PIN