Provider Demographics
NPI:1780487918
Name:SONG, JEFFREY
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:SONG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 OLENTANGY RIVER RD STE 2000
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 OLENTANGY RIVER RD STE 2000
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3159
Practice Address - Country:US
Practice Address - Phone:614-293-8155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH57.257829208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program