Provider Demographics
NPI:1144207796
Name:SONG, NAMSOO (MD)
Entity type:Individual
Prefix:
First Name:NAMSOO
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 DRAPER RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02030-1610
Mailing Address - Country:US
Mailing Address - Phone:508-785-2972
Mailing Address - Fax:
Practice Address - Street 1:22 DRAPER RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:MA
Practice Address - Zip Code:02030-1610
Practice Address - Country:US
Practice Address - Phone:508-785-2972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA450482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA59370Medicare UPIN
MASOJ10037Medicare ID - Type Unspecified