Provider Demographics
NPI:1467114413
Name:AMBROISE, WIDMAYER (MD)
Entity Type:Individual
Prefix:DR
First Name:WIDMAYER
Middle Name:
Last Name:AMBROISE
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 1:55 PARK ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2363
Mailing Address - Country:US
Mailing Address - Phone:774-719-3922
Mailing Address - Fax:
Practice Address - Street 1:55 PARK ST APT 2
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2363
Practice Address - Country:US
Practice Address - Phone:774-719-3922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225C00000X, 171R00000X, 172A00000X, 225800000X, 251K00000X, 251S00000X, 372500000X, 372600000X, 376J00000X, 385HR2055X, 385HR2060X, 253Z00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorGroup - Single Specialty
No171R00000XOther Service ProvidersInterpreter
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No172A00000XOther Service ProvidersDriver
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child