Provider Demographics
NPI:1558389692
Name:AMBROSE, MARTIN P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:P
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8881 NORTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1333
Mailing Address - Country:US
Mailing Address - Phone:937-832-5292
Mailing Address - Fax:937-832-7505
Practice Address - Street 1:3095 DAYTON XENIA RD STE 900
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-4305
Practice Address - Country:US
Practice Address - Phone:937-458-4010
Practice Address - Fax:937-458-4019
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH060025207RC0200X, 207RP1001X
OH35.060025207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0790907Medicaid
OHA03355Medicare UPIN
OH0790907Medicaid