Provider Demographics
NPI:1316300940
Name:AMBROSE, MAHOGANY JERVON (MD)
Entity type:Individual
Prefix:MRS
First Name:MAHOGANY
Middle Name:JERVON
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAHOGANY
Other - Middle Name:JERVON
Other - Last Name:MERRIFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8005
Mailing Address - Country:US
Mailing Address - Phone:239-936-2316
Mailing Address - Fax:
Practice Address - Street 1:14551 HOPE CENTER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4705
Practice Address - Country:US
Practice Address - Phone:239-936-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI33772085R0202X
FLME1669352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology