Provider Demographics
NPI:1598746232
Name:SONG, JOON KYUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:JOON
Middle Name:KYUNG
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:PO BOX 1535
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98401-1535
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1900
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000346942085N0700X, 2085R0202X
ORMD1622092085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1092213Medicaid
OR500671175Medicaid
WA0236611OtherLABOR AND INDUSTRIES-TRA
WA0236614OtherLABOR AND INDUSTRIES-UNION AVENUE OPEN MRI
WA8947494OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WA8947866OtherLABOR AND INDUSTRIES CRIME VICTIMS-UNION AVENUE OPEN MRI
WA8947866OtherLABOR AND INDUSTRIES CRIME VICTIMS-UNION AVENUE OPEN MRI
NY02497423Medicaid
WAP00707026OtherRR MEDICARE-TRA
WAP00946466OtherRR MEDICARE-UNION AVENUE OPEN MRI
ORR174353OtherPTAN-PENDLETON, OREGON
WA7820707OtherDSHS-TRA
WA0236611OtherLABOR AND INDUSTRIES-TRA
WA8947494OtherLABOR AND INDUSTRIES CRIME VICTIMS-TRA
WA7087158OtherDSHS-UAOM
NYG88397Medicare UPIN
WAG8873544Medicare PIN
WA0236614OtherLABOR AND INDUSTRIES-UNION AVENUE OPEN MRI
WAG8873545Medicare PIN
WAG8886633Medicare PIN
WA8511867Medicare PIN