Healthcare Provider Details

I. General information

NPI: 1972561405
Provider Name (Legal Business Name): WAYNE L AMBROZE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 MERIDIAN MARKS RD SUITE 180
ATLANTA GA
30342-4763
US

IV. Provider business mailing address

5445 MERIDIAN MARKS RD SUITE 180
ATLANTA GA
30342-4763
US

V. Phone/Fax

Practice location:
  • Phone: 770-277-4277
  • Fax: 404-252-5745
Mailing address:
  • Phone: 770-277-4277
  • Fax: 404-252-5745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number033019
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: