Healthcare Provider Details

I. General information

NPI: 1679599765
Provider Name (Legal Business Name): DAVID D SONG M.D./PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 BROCKTON AVE STE 302-2
RIVERSIDE CA
92506-0174
US

IV. Provider business mailing address

1501 VIOLET ST
COLTON CA
92324-1603
US

V. Phone/Fax

Practice location:
  • Phone: 951-742-5255
  • Fax: 951-717-8609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA72825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: