Provider Demographics
NPI:1275712218
Name:AMBROSE, JOSEPH M (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12880 CARMEL COUNTRY RD # D110
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3137
Mailing Address - Country:US
Mailing Address - Phone:858-350-1302
Mailing Address - Fax:
Practice Address - Street 1:12880 CARMEL COUNTRY RD # D110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3137
Practice Address - Country:US
Practice Address - Phone:858-350-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7659T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU73865Medicare UPIN