Healthcare Provider Details

I. General information

NPI: 1063502375
Provider Name (Legal Business Name): HANJOON MIKE SONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3096 PEACHTREE INDUSTRIAL BLVD
DULUTH GA
30097
US

IV. Provider business mailing address

3096 PEACHTREE INDUSTRIAL BLVD
DULUTH GA
30097
US

V. Phone/Fax

Practice location:
  • Phone: 770-495-1477
  • Fax: 770-495-1488
Mailing address:
  • Phone: 770-495-1477
  • Fax: 770-495-1488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number057679
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: