Provider Demographics
NPI:1356373096
Name:PRINCE, MARTIN R (MD, PHD, FACR)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:R
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD, PHD, FACR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5104
Mailing Address - Country:US
Mailing Address - Phone:212-746-6801
Mailing Address - Fax:212-421-1844
Practice Address - Street 1:416 E 55TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5104
Practice Address - Country:US
Practice Address - Phone:212-746-6801
Practice Address - Fax:212-421-1844
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2133432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02186203OtherMEDICAID GROUP #
NY01925713Medicaid
NYW35021OtherMEDICARE GROUP #
NY02186203OtherMEDICAID GROUP #
NY01925713Medicaid