Healthcare Provider Details

I. General information

NPI: 1205074002
Provider Name (Legal Business Name): JASON JEONG HWAN SONG M.D., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 17TH ST UNIT 202
SAINT CLOUD FL
34769-4939
US

IV. Provider business mailing address

2801 17TH ST UNIT 202
SAINT CLOUD FL
34769-4939
US

V. Phone/Fax

Practice location:
  • Phone: 407-906-1328
  • Fax: 866-425-8143
Mailing address:
  • Phone: 407-906-1328
  • Fax: 866-425-8143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME123792
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME123792
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number236756
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number123792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: