Provider Demographics
NPI:1437169950
Name:SONG, JONG E (MD)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:E
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 1:24907 SUNNYMEAD BLVD
Mailing Address - Street 2:STE E
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-242-6009
Mailing Address - Fax:951-247-7498
Practice Address - Street 1:24907 SUNNYMEAD BLVD
Practice Address - Street 2:STE E
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-242-6009
Practice Address - Fax:951-247-7498
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A342640Medicaid
A27434Medicare UPIN
00A342640Medicare ID - Type Unspecified