Healthcare Provider Details

I. General information

NPI: 1275563041
Provider Name (Legal Business Name): DANIEL SONG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N BROADWAY SUITE 1440
BALTIMORE MD
21231-1146
US

IV. Provider business mailing address

PO BOX 64474
BALTIMORE MD
21264-4474
US

V. Phone/Fax

Practice location:
  • Phone: 401-502-5875
  • Fax:
Mailing address:
  • Phone: 410-502-5875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberD61866
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: