Provider Demographics
NPI:1871050245
Name:SONG, ILSEONG (PT, DPT)
Entity type:Individual
Prefix:
First Name:ILSEONG
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6306 SEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2626
Mailing Address - Country:US
Mailing Address - Phone:858-284-1133
Mailing Address - Fax:
Practice Address - Street 1:7340 MIRAMAR RD STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4224
Practice Address - Country:US
Practice Address - Phone:858-284-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA295985OtherPT LICENSE