Provider Demographics
NPI:1356720049
Name:KO, DAVID SONG (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SONG
Last Name:KO
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:PO BOX 746871
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:330 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-3803
Practice Address - Country:US
Practice Address - Phone:860-928-2736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61443176207Q00000X
CT82804207Q00000X
VA0102205469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine