Provider Demographics
NPI:1285660076
Name:AMBALONG, MARIA PHARAH PAGUSARA (MD)
Entity Type:Individual
Prefix:
First Name:MARIA PHARAH
Middle Name:PAGUSARA
Last Name:AMBALONG
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 1:9250 AMBERTON PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3224
Mailing Address - Country:US
Mailing Address - Phone:682-236-3656
Mailing Address - Fax:
Practice Address - Street 1:9250 AMBERTON PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3224
Practice Address - Country:US
Practice Address - Phone:682-236-3656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9277207QG0300X
MO2006034474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365729801Medicaid
MO207455304Medicaid
MO326772642Medicare PIN
TX528544YKPWMedicare PIN