Provider Demographics
NPI:1114911641
Name:PRINCE, BOBBY D (MD)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:D
Last Name:PRINCE
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:PO BOX 71367
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31708-1367
Mailing Address - Country:US
Mailing Address - Phone:229-435-0525
Mailing Address - Fax:229-434-9827
Practice Address - Street 1:2311 LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3183
Practice Address - Country:US
Practice Address - Phone:229-435-0525
Practice Address - Fax:229-434-9827
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035735207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000642661MMedicaid
GAGRP4292OtherMEDICARE GROUP NUMBER
GA000642661MMedicaid
GA20NCCQXMedicare Oscar/Certification