Provider Demographics
NPI:1538150222
Name:PRINCE, YVONNE M (MD)
Entity type:Individual
Prefix:DR
First Name:YVONNE
Middle Name:M
Last Name:PRINCE
Suffix:
Gender:F
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 69
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-0069
Mailing Address - Country:US
Mailing Address - Phone:573-729-6112
Mailing Address - Fax:573-729-4035
Practice Address - Street 1:35629 HIGHWAY 72 BLDG II
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-7217
Practice Address - Country:US
Practice Address - Phone:573-729-6112
Practice Address - Fax:573-729-4035
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207705104Medicaid
001012184Medicare ID - Type Unspecified
F48249Medicare UPIN