Healthcare Provider Details

I. General information

NPI: 1871025676
Provider Name (Legal Business Name): JUN SONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 W MARKHAM ST # 540
LITTLE ROCK AR
72205-7101
US

IV. Provider business mailing address

4301 W MARKHAM ST # 783
LITTLE ROCK AR
72205-7101
US

V. Phone/Fax

Practice location:
  • Phone: 501-686-8000
  • Fax: 501-526-5148
Mailing address:
  • Phone: 501-686-8000
  • Fax: 501-526-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberE-17951
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberE-17951
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: