Provider Demographics
NPI:1841391323
Name:EUBANKS, PRINCE JEROME (MD)
Entity Type:Individual
Prefix:
First Name:PRINCE
Middle Name:JEROME
Last Name:EUBANKS
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 1:19785 W 12 MILE RD
Mailing Address - Street 2:#268
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2543
Mailing Address - Country:US
Mailing Address - Phone:313-273-2330
Mailing Address - Fax:313-273-2604
Practice Address - Street 1:20526 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1201
Practice Address - Country:US
Practice Address - Phone:313-273-2330
Practice Address - Fax:313-273-2604
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044813207RA0401X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine