Provider Demographics
NPI:1477506459
Name:AMBROZIAK, JAROSLAW M (MD)
Entity Type:Individual
Prefix:
First Name:JAROSLAW
Middle Name:M
Last Name:AMBROZIAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:M
Other - Last Name:AMBROZIAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:103
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2023
Mailing Address - Country:US
Mailing Address - Phone:803-254-5171
Mailing Address - Fax:803-779-7403
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:103
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-254-5171
Practice Address - Fax:803-779-7403
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21987207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC080184007OtherRAILROAD MEDICARE
SCT62704Medicaid
SC080184007OtherRAILROAD MEDICARE
SCG88602Medicare UPIN