Provider Demographics
NPI:1386716264
Name:AMBROSE, DOUGLAS F (DC, FIAMA)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:F
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:DC, FIAMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 SOUTHLAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-3042
Mailing Address - Country:US
Mailing Address - Phone:804-897-6130
Mailing Address - Fax:804-897-6130
Practice Address - Street 1:535 SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-3042
Practice Address - Country:US
Practice Address - Phone:804-897-6130
Practice Address - Fax:804-924-2168
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001902111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350000860Medicare UPIN