Provider Demographics
NPI:1659837003
Name:PRINCE, TODD W
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:W
Last Name:PRINCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 TIMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-1044
Mailing Address - Country:US
Mailing Address - Phone:585-730-0756
Mailing Address - Fax:
Practice Address - Street 1:22 TIMBERWOOD DR
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-1044
Practice Address - Country:US
Practice Address - Phone:585-730-0756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05126898Medicaid