Basic Information
| Provider Information | |||||||||
| NPI: | 1588841233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMBROSE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 8667954020 | ||||||||
| Practice Location | |||||||||
| Address1: | 12300 JEFFERSON AVE STE 126 | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236020003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572494330 | ||||||||
| FaxNumber: | 7572494303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 06/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001730 | VA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.