Provider Demographics
NPI:1861501991
Name:PRINCE, JOHN MARTIN JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARTIN
Last Name:PRINCE
Suffix:JR
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:PO BOX 94670
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-4670
Mailing Address - Country:US
Mailing Address - Phone:405-682-3303
Mailing Address - Fax:405-384-6793
Practice Address - Street 1:10904 KINGSTON PIKE STE 103
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2953
Practice Address - Country:US
Practice Address - Phone:865-588-8831
Practice Address - Fax:868-588-8841
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22127207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3841549Medicaid
TN290011982OtherRR MEDICARE PIN
TN3717547Medicare ID - Type UnspecifiedLEGACY GROUP
TN3841542Medicare ID - Type UnspecifiedLEGACY PIN
B06319Medicare UPIN