Provider Demographics
NPI:1760756597
Name:SONG, MICHAEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:SONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 COGGINS DR APT 174
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4404
Mailing Address - Country:US
Mailing Address - Phone:909-471-6515
Mailing Address - Fax:
Practice Address - Street 1:450 N WIGET LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2408
Practice Address - Country:US
Practice Address - Phone:925-691-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-24
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11747208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine