Provider Demographics
NPI:1629692769
Name:PRINCE, JEREMY KEON (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KEON
Last Name:PRINCE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 MLK RD
Mailing Address - Street 2:
Mailing Address - City:ALICEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35442
Mailing Address - Country:US
Mailing Address - Phone:256-225-1339
Mailing Address - Fax:
Practice Address - Street 1:1665 S GREEN ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-6556
Practice Address - Country:US
Practice Address - Phone:662-377-2189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPRIN-CYGCZT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine