Provider Demographics
NPI:1154313203
Name:PRINCE, CLIFTON JARRETT (MD)
Entity Type:Individual
Prefix:
First Name:CLIFTON
Middle Name:JARRETT
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 229
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764
Mailing Address - Country:US
Mailing Address - Phone:740-342-5107
Mailing Address - Fax:740-342-5351
Practice Address - Street 1:401 LINCOLN PARK DRIVE
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764
Practice Address - Country:US
Practice Address - Phone:740-342-5107
Practice Address - Fax:740-342-5351
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2432924Medicaid
OH2432924Medicaid
OHPR4119913Medicare ID - Type Unspecified