Provider Demographics
NPI:1962424382
Name:PRINCE, JOHN WESLEY JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:PRINCE
Suffix:JR
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:PO BOX 1650
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44309-1650
Mailing Address - Country:US
Mailing Address - Phone:330-864-8900
Mailing Address - Fax:330-869-8924
Practice Address - Street 1:55 FOUNDATION DR
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-9815
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY36068207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50005474OtherPASSPORT
KYP00015881OtherRR-MEDICARE
KY000000259709OtherANTHEM
KY64046618Medicaid
KY0693588Medicare ID - Type Unspecified
KY64046618Medicaid