Provider Demographics
NPI:1598991184
Name:PRINCE, KENNETH RODNEY (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RODNEY
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:524 SKYMARKS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7254
Practice Address - Country:US
Practice Address - Phone:904-696-7333
Practice Address - Fax:904-696-1926
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12449207R00000X
NMDO2023-1086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01666432OtherRR MEDICARE
FLP01666432OtherRR MEDICARE