Healthcare Provider Details

I. General information

NPI: 1588641740
Provider Name (Legal Business Name): MARK J AMBRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14540 PRAIRIE LAKES BLVD N STE 200
NOBLESVILLE IN
46060-4370
US

IV. Provider business mailing address

250 W 96TH ST # 520
INDIANAPOLIS IN
46260-1316
US

V. Phone/Fax

Practice location:
  • Phone: 317-578-4193
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01028101
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: