Healthcare Provider Details

I. General information

NPI: 1194163170
Provider Name (Legal Business Name): SEOKHAN SONG D.O., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KYLE SONG D.O., M.S.

II. Dates (important events)

Enumeration Date: 06/12/2013
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14678 N DEL WEBB BLVD
SUN CITY AZ
85351-2137
US

IV. Provider business mailing address

14678 N DEL WEBB BLVD
SUN CITY AZ
85351-2137
US

V. Phone/Fax

Practice location:
  • Phone: 623-933-8289
  • Fax: 623-933-2596
Mailing address:
  • Phone: 623-933-8289
  • Fax: 623-933-2596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number011740
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: