Provider Demographics
NPI:1134548589
Name:PRINCE, SARA DAVIS
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:DAVIS
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 CHESTNUT ST
Mailing Address - Street 2:APARTMENT 1712
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5127
Mailing Address - Country:US
Mailing Address - Phone:215-990-5103
Mailing Address - Fax:
Practice Address - Street 1:1600 ROCKLAND RD STE 2B80
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-5874
Practice Address - Fax:302-651-5954
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD460569208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program