Provider Demographics
NPI:1366183790
Name:PRINCE, DUSTIN (DO)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 INDIANA AVENUE
Mailing Address - Street 2:LOCKEFIELD VILLAGE 1164
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2915
Mailing Address - Country:US
Mailing Address - Phone:317-278-0300
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1245
Practice Address - Country:US
Practice Address - Phone:317-944-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007373A207Q00000X
IN11022381A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300063355Medicaid