Provider Demographics
NPI:1447224811
Name:SONG, JUHO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUHO
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 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2546 BALLTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-1079
Practice Address - Country:US
Practice Address - Phone:518-372-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1623992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01033527Medicaid
NY01033527Medicaid
NYCC1816Medicare ID - Type Unspecified