Basic Information
| Provider Information | |||||||||
| NPI: | 1538342043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | JAEYOUNG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 NEWELL AVE | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945965120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252954000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2500 ALHAMBRA AVE | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945533156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253705110 | ||||||||
| FaxNumber: | 9253705142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2007 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A85362 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.