Provider Demographics
NPI:1851607394
Name:AMBWANI, JAGDISH C (MD)
Entity Type:Individual
Prefix:DR
First Name:JAGDISH
Middle Name:C
Last Name:AMBWANI
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 1:1400 W STATE ROAD 434 STE 1010
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3817
Mailing Address - Country:US
Mailing Address - Phone:407-644-9970
Mailing Address - Fax:407-644-6926
Practice Address - Street 1:1400 W STATE ROAD 434 STE 1010
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750
Practice Address - Country:US
Practice Address - Phone:407-644-9970
Practice Address - Fax:407-644-6926
Is Sole Proprietor?:No
Enumeration Date:2010-08-22
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108141208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003038200Medicaid