Provider Demographics
NPI:1487912721
Name:SONG, CLIFFORD (MD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
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 1:1210 LARRABEE ST # 8
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-6104
Mailing Address - Country:US
Mailing Address - Phone:703-585-4924
Mailing Address - Fax:
Practice Address - Street 1:10400 HALIGUS RD FL 2
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9553
Practice Address - Country:US
Practice Address - Phone:224-654-0000
Practice Address - Fax:224-654-0000
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA76210207L00000X
CAC193443207L00000X
390200000X
IL036170016207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program