Provider Demographics
NPI:1184858334
Name:DILDEEP, AMBUJAKSHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMBUJAKSHAN
Middle Name:
Last Name:DILDEEP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-752-2305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:3737 SOUTHERN BLVD
Practice Address - Street 2:SUITE 2000
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1262
Practice Address - Country:US
Practice Address - Phone:937-610-1915
Practice Address - Fax:937-610-1917
Is Sole Proprietor?:No
Enumeration Date:2009-05-02
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35122500208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094140Medicaid
OH0094140Medicaid