Provider Demographics
NPI:1720076011
Name:AMBRAD, JAMIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMIEL
Middle Name:J
Last Name:AMBRAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 KINGSTOWN RD
Mailing Address - Street 2:UNIT B5
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-3011
Mailing Address - Country:US
Mailing Address - Phone:401-783-1022
Mailing Address - Fax:401-783-4004
Practice Address - Street 1:730 KINGSTOWN RD
Practice Address - Street 2:UNIT B5
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-3011
Practice Address - Country:US
Practice Address - Phone:401-783-1022
Practice Address - Fax:401-783-4004
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214029207Q00000X
RIMD10880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJA84304Medicaid
H63930Medicare UPIN
089022646Medicare ID - Type Unspecified