Provider Demographics
NPI:1083769566
Name:AMBACH, MARY ANTONIETTE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANTONIETTE
Last Name:AMBACH
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 1:6125 PASEO DEL NORTE STE 100
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1113
Mailing Address - Country:US
Mailing Address - Phone:760-909-2355
Mailing Address - Fax:760-448-5363
Practice Address - Street 1:6125 PASEO DEL NORTE STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011
Practice Address - Country:US
Practice Address - Phone:760-909-2355
Practice Address - Fax:760-448-5363
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1086222081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00231OtherBCBS
FL1083769566OtherCIGNA
FL00231OtherBCBS
FLI70854Medicare UPIN