Provider Demographics
NPI:1336265495
Name:SONG, JONATHAN (OMD, MD, PHD, LAC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:OMD, MD, PHD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6255 UNIVERSITY AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-3485
Mailing Address - Country:US
Mailing Address - Phone:608-238-3333
Mailing Address - Fax:608-238-3374
Practice Address - Street 1:6255 UNIVERSITY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3485
Practice Address - Country:US
Practice Address - Phone:608-238-3333
Practice Address - Fax:608-238-3374
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI232171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist