Provider Demographics
NPI:1093920746
Name:AMBUSKE, GREGORY A (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:AMBUSKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 NE 125TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5833
Mailing Address - Country:US
Mailing Address - Phone:888-852-6672
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:6915 TUTT BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3591
Practice Address - Country:US
Practice Address - Phone:719-445-1292
Practice Address - Fax:719-591-6486
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013889207R00000X
CODR.0056364207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000156203Medicaid
PAFA0065323OtherDEA
PA1019008580002Medicaid