Provider Demographics
NPI:1669431094
Name:SONG, CHENG CHIEN (MD)
Entity type:Individual
Prefix:DR
First Name:CHENG
Middle Name:CHIEN
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 1:1001 12TH AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3929
Mailing Address - Country:US
Mailing Address - Phone:817-810-9997
Mailing Address - Fax:817-810-9978
Practice Address - Street 1:1001 12TH AVE STE 154
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3929
Practice Address - Country:US
Practice Address - Phone:817-810-9997
Practice Address - Fax:817-810-9978
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2010207V00000X
TXR0003207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0964413Medicaid
00234MMedicare ID - Type Unspecified
TX0964413Medicaid