Provider Demographics
NPI:1194163170
Name:SONG, SEOKHAN (DO, MS)
Entity type:Individual
Prefix:DR
First Name:SEOKHAN
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:DO, MS
Other - Prefix:DR
Other - First Name:KYLE
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO, MS
Mailing Address - Street 1:504 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52349-2254
Mailing Address - Country:US
Mailing Address - Phone:319-472-6300
Mailing Address - Fax:
Practice Address - Street 1:504 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:IA
Practice Address - Zip Code:52349-2254
Practice Address - Country:US
Practice Address - Phone:319-472-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204062207Q00000X
IADO-05789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine