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 1:9149 ESTATE THOMAS STE 103
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802-3132
Mailing Address - Country:US
Mailing Address - Phone:615-484-6892
Mailing Address - Fax:340-776-0228
Practice Address - Street 1:10920 MCKINLEY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6471
Practice Address - Country:US
Practice Address - Phone:813-745-8535
Practice Address - Fax:813-449-8398
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI33772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology