Provider Demographics
NPI:1821006164
Name:PRINCE, ROBERT MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:PRINCE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:109 MEDICAL PARK LN
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-4977
Mailing Address - Country:US
Mailing Address - Phone:936-291-8282
Mailing Address - Fax:936-291-9863
Practice Address - Street 1:109 MEDICAL PARK LN
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-4977
Practice Address - Country:US
Practice Address - Phone:936-291-8282
Practice Address - Fax:936-291-9863
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5947TG152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX645287164Medicaid
TX00308PMedicare ID - Type Unspecified
TX645287164Medicaid