Basic Information
| Provider Information | |||||||||
| NPI: | 1154313203 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRINCE | ||||||||
| FirstName: | CLIFTON | ||||||||
| MiddleName: | JARRETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 229 | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403425107 | ||||||||
| FaxNumber: | 7403425351 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 LINCOLN PARK DRIVE | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403425107 | ||||||||
| FaxNumber: | 7403425351 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2005 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35083418 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2432924 | 05 | OH | MEDICAID |