Provider Demographics
NPI:1831932623
Name:SONG, KYUHO
Entity type:Individual
Prefix:
First Name:KYUHO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 PLAINS RD APT D104
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2511
Mailing Address - Country:US
Mailing Address - Phone:949-973-1827
Mailing Address - Fax:
Practice Address - Street 1:5324 HARRY HINES BOULEVARD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-0001
Practice Address - Country:US
Practice Address - Phone:949-973-1827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program