Provider Demographics
NPI:1790789055
Name:D'AMBROSIO, GINA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:D'AMBROSIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:DAOUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-793-6140
Mailing Address - Fax:865-560-8948
Practice Address - Street 1:36123 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1216
Practice Address - Country:US
Practice Address - Phone:734-464-0887
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014605207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4846745Medicaid
MI1790789055OtherNPI #
MI700F329470OtherBLUE CROSS CPIN
I01557Medicare UPIN
MIP28070025Medicare PIN