Provider Demographics
NPI:1538467394
Name:SONG, SUNGCHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNGCHAN
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 1:8250 WOODMAN AVE
Mailing Address - Street 2:NORTH 2 BUILDING
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5427
Mailing Address - Country:US
Mailing Address - Phone:619-481-1590
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:818-375-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115376208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation