Provider Demographics
NPI:1770140113
Name:AMBROSE, ADRIAN KYLE (MD)
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:KYLE
Last Name:AMBROSE
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 1:9679 LAKE NONA VILLAGE PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7310
Mailing Address - Country:US
Mailing Address - Phone:407-277-9242
Mailing Address - Fax:407-636-7805
Practice Address - Street 1:9679 LAKE NONA VILLAGE PL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7310
Practice Address - Country:US
Practice Address - Phone:407-277-9242
Practice Address - Fax:407-636-7805
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
FLME164174207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119191900Medicaid