Provider Demographics
NPI:1669532842
Name:SONG, TAIIL TED (DO)
Entity type:Individual
Prefix:DR
First Name:TAIIL
Middle Name:TED
Last Name:SONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11203 BRIDGEPORT WAY SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3002
Mailing Address - Country:US
Mailing Address - Phone:253-589-1380
Mailing Address - Fax:
Practice Address - Street 1:11203 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3002
Practice Address - Country:US
Practice Address - Phone:253-589-1380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002163207KA0200X, 207K00000X
ARE-2006207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
No207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology