Provider Demographics
NPI:1356416168
Name:SONG, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
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 1:4500 S LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:214-413-3741
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-413-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU0443207R00000X, 2083C0008X
HIMD-12260207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083C0008XAllopathic & Osteopathic PhysiciansPreventive MedicineClinical Informatics