Provider Demographics
NPI:1225018443
Name:AMBROSE, LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:AMBROSE
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 1:1777 HAMBURG TPKE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5211
Mailing Address - Country:US
Mailing Address - Phone:973-839-8700
Mailing Address - Fax:973-839-1681
Practice Address - Street 1:1777 HAMBURG TPKE
Practice Address - Street 2:SUITE 203
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-5211
Practice Address - Country:US
Practice Address - Phone:973-839-8700
Practice Address - Fax:973-839-1681
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA40369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
D19355Medicare UPIN
NJ583215AXRMedicare PIN