Provider Demographics
NPI:1679599765
Name:SONG, DAVID D (MD/PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:D
Last Name:SONG
Suffix:
Gender:
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 VIOLET ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4646 BROCKTON AVE STE 302-2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0174
Practice Address - Country:US
Practice Address - Phone:951-742-5255
Practice Address - Fax:951-717-8609
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA728252084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A728250Medicaid
CA00A728250Medicaid
CAWA72825AMedicare ID - Type Unspecified