Provider Demographics
NPI:1336198597
Name:PIYAKA, SONG K (MD)
Entity Type:Individual
Prefix:
First Name:SONG
Middle Name:K
Last Name:PIYAKA
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 1:1101 LAKE ST
Mailing Address - Street 2:#304
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1085
Mailing Address - Country:US
Mailing Address - Phone:708-763-0727
Mailing Address - Fax:708-763-0827
Practice Address - Street 1:1101 LAKE ST
Practice Address - Street 2:#304
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1085
Practice Address - Country:US
Practice Address - Phone:708-763-0727
Practice Address - Fax:708-763-0827
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D12876Medicare UPIN
482632Medicare ID - Type Unspecified