Provider Demographics
NPI:1336105329
Name:AMBROZIAK, MICHAEL T (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:AMBROZIAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1331
Mailing Address - Country:US
Mailing Address - Phone:989-667-4663
Mailing Address - Fax:989-667-1964
Practice Address - Street 1:3801 WILDER RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2301
Practice Address - Country:US
Practice Address - Phone:989-667-4663
Practice Address - Fax:989-667-1964
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001787213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3346538Medicaid
MI0M22980002Medicare PIN
MI3346538Medicaid