Provider Demographics
NPI:1093808446
Name:SONG, JOHN IN-TAEK (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:IN-TAEK
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 1:960 JOHNSON FERRY RD STE 335
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1625
Mailing Address - Country:US
Mailing Address - Phone:404-257-1482
Mailing Address - Fax:404-257-1483
Practice Address - Street 1:960 JOHNSON FERRY RD STE 335
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1625
Practice Address - Country:US
Practice Address - Phone:404-257-1482
Practice Address - Fax:404-257-1483
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40893207Y00000X
GA87662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO74205579Medicaid
COC474318Medicare PIN