Provider Demographics
NPI:1972561405
Name:AMBROZE, WAYNE L (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:AMBROZE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5445 MERIDIAN MARKS RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4763
Mailing Address - Country:US
Mailing Address - Phone:770-277-4277
Mailing Address - Fax:404-252-5745
Practice Address - Street 1:5445 MERIDIAN MARKS RD
Practice Address - Street 2:SUITE 180
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4763
Practice Address - Country:US
Practice Address - Phone:770-277-4277
Practice Address - Fax:404-252-5745
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033019208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
52022684OtherBCBS
1406030OtherUNITED HEALTHCAREE
216188012OtherCIGNA HMO
4120130OtherAETNA NON HMO
1129OtherKAISER
519446OtherAETNA HMO
GA00432011BMedicaid
519446OtherAETNA HMO
52022684OtherBCBS
1406030OtherUNITED HEALTHCAREE