Provider Demographics
NPI:1922169713
Name:AMBROSE, MICHAEL FRANK (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FRANK
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WOODLAND RUN
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8705
Mailing Address - Country:US
Mailing Address - Phone:330-533-1067
Mailing Address - Fax:
Practice Address - Street 1:61 TALSMAN DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1207
Practice Address - Country:US
Practice Address - Phone:330-702-0503
Practice Address - Fax:330-533-6111
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4101632Medicare ID - Type Unspecified
OHU94160Medicare UPIN
OH5258970001Medicare NSC