Provider Demographics
NPI:1487068904
Name:SONG, JOSEPH (MA, MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:MA, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 BRANNAN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4310
Mailing Address - Country:US
Mailing Address - Phone:678-284-4686
Mailing Address - Fax:
Practice Address - Street 1:3855 PLEASANT HILL RD STE 220
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8030
Practice Address - Country:US
Practice Address - Phone:770-979-9427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA83055208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014018120OtherMISSOURI LICENSE NUMBER