Healthcare Provider Details

I. General information

NPI: 1952386518
Provider Name (Legal Business Name): SANG HO SONG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 FORSGATE DR 107
JAMESBURG NJ
08831-1385
US

IV. Provider business mailing address

241 FORSGATE DR STE 107
JAMESBURG NJ
08831-1385
US

V. Phone/Fax

Practice location:
  • Phone: 732-660-8715
  • Fax: 732-906-0124
Mailing address:
  • Phone: 732-660-8715
  • Fax: 732-906-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MB07701500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number231625
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: