Healthcare Provider Details

I. General information

NPI: 1891735676
Provider Name (Legal Business Name): STANLEY G. AMBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W. VISTA WAY SUITE 180
VISTA CA
92083-6033
US

IV. Provider business mailing address

3860 CALLE FORTUNADA SUITE 200
SAN DIEGO CA
92123-4802
US

V. Phone/Fax

Practice location:
  • Phone: 760-945-3434
  • Fax: 760-945-6761
Mailing address:
  • Phone: 858-636-4300
  • Fax: 858-836-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG77814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: