Provider Demographics
NPI:1205074002
Name:SONG, JASON JEONG HWAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:JEONG HWAN
Last Name:SONG
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 17TH ST UNIT 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4939
Mailing Address - Country:US
Mailing Address - Phone:407-906-1328
Mailing Address - Fax:866-425-8143
Practice Address - Street 1:2801 17TH ST UNIT 202
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-4939
Practice Address - Country:US
Practice Address - Phone:407-906-1328
Practice Address - Fax:866-425-8143
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123792208100000X, 2081P2900X
MA236756390200000X
FL123792208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015031800Medicaid