Provider Demographics
NPI:1629056494
Name:PRINS, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:PRINS
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 1:83 E BAY AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3102
Mailing Address - Country:US
Mailing Address - Phone:609-597-7100
Mailing Address - Fax:609-597-7648
Practice Address - Street 1:83 E BAY AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3102
Practice Address - Country:US
Practice Address - Phone:609-597-7100
Practice Address - Fax:609-597-7648
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA32556207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C54563Medicare UPIN
NJPR441874Medicare ID - Type Unspecified