Provider Demographics
NPI:1467879379
Name:SONG, JEREMY JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JOHN
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 1:6630 S MCCARRAN BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6186
Mailing Address - Country:US
Mailing Address - Phone:775-525-9151
Mailing Address - Fax:
Practice Address - Street 1:6630 S MCCARRAN BLVD STE 202
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6186
Practice Address - Country:US
Practice Address - Phone:775-525-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME143653208G00000X
NV27196208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106741100Medicaid