Provider Demographics
NPI:1205872199
Name:SOLANO, AMBROSIO A (MD)
Entity type:Individual
Prefix:DR
First Name:AMBROSIO
Middle Name:A
Last Name:SOLANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:AMBROSE
Other - Middle Name:A
Other - Last Name:SOLANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:#121
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-751-3183
Practice Address - Street 1:900 17TH ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-2448
Practice Address - Country:US
Practice Address - Phone:580-256-5511
Practice Address - Fax:405-751-3183
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11827207PE0004X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100229540AMedicaid
OKOK401586Medicare PIN
OK100229540AMedicaid