Provider Demographics
NPI:1104442573
Name:PRINCE, OCTAVIA C
Entity type:Individual
Prefix:DR
First Name:OCTAVIA
Middle Name:C
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6414 PARK HEIGHTS AVE STE G1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3064
Mailing Address - Country:US
Mailing Address - Phone:404-263-1004
Mailing Address - Fax:
Practice Address - Street 1:6414 PARK HEIGHTS AVE STE G1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3064
Practice Address - Country:US
Practice Address - Phone:404-263-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD887504900Medicaid