Provider Demographics
NPI:1376832998
Name:LI, SONG (MD)
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:
Last Name:LI
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 1:11970 N CENTRAL EXPY STE 550
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3958
Mailing Address - Country:US
Mailing Address - Phone:972-940-9520
Mailing Address - Fax:972-940-9535
Practice Address - Street 1:11970 N CENTRAL EXPY STE 550
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3958
Practice Address - Country:US
Practice Address - Phone:972-940-9520
Practice Address - Fax:972-940-9535
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU3418207RA0001X
WAMD60549052207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1376832998Medicaid