Provider Demographics
NPI:1497108856
Name:PHILIP, PRINCE (MD)
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:
Last Name:PHILIP
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 1:3458 NEELY RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-5312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 N GALLOWAY AVE STE 116
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5737
Practice Address - Country:US
Practice Address - Phone:972-426-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10471800208D00000X, 207R00000X
TXU6050207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice