Provider Demographics
NPI:1518250174
Name:AMBRUSO, SOPHIA LOUISE (DO)
Entity Type:Individual
Prefix:DR
First Name:SOPHIA
Middle Name:LOUISE
Last Name:AMBRUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:SOPHIA
Other - Middle Name:LOUISE
Other - Last Name:HINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:3 BLUE GROUSE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-5704
Mailing Address - Country:US
Mailing Address - Phone:303-748-6419
Mailing Address - Fax:
Practice Address - Street 1:3 BLUE GROUSE RIDGE RD
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80127-5704
Practice Address - Country:US
Practice Address - Phone:208-422-1314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRO1272207R00000X
CODR.0055382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine