Provider Demographics
NPI:1558414763
Name:IM, DAVID SONGCHAN (DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SONGCHAN
Last Name:IM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 E. COLORADO BLVD.
Mailing Address - Street 2:#202
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107
Mailing Address - Country:US
Mailing Address - Phone:626-449-9910
Mailing Address - Fax:626-449-9382
Practice Address - Street 1:2245 E. COLORADO BLVD.
Practice Address - Street 2:#202
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107
Practice Address - Country:US
Practice Address - Phone:626-449-9910
Practice Address - Fax:626-449-9382
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT269332251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT26933AMedicare ID - Type Unspecified