Provider Demographics
NPI:1902260227
Name:SONG, JONATHAN K (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:K
Last Name:SONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E MISSOURI AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8917
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:645 E MISSOURI AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1351
Practice Address - Country:US
Practice Address - Phone:602-262-8917
Practice Address - Fax:602-262-8890
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009208208100000X, 2081P2900X
IL125069929208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine