Provider Demographics
NPI:1144335324
Name:WARSZAWA-AMBROS, MARYLA (MD)
Entity type:Individual
Prefix:
First Name:MARYLA
Middle Name:
Last Name:WARSZAWA-AMBROS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTURY HILL DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2162
Mailing Address - Country:US
Mailing Address - Phone:518-783-5563
Mailing Address - Fax:518-785-5708
Practice Address - Street 1:10 CENTURY HILL DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2162
Practice Address - Country:US
Practice Address - Phone:518-783-5563
Practice Address - Fax:518-785-5708
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185640-12080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01260746Medicaid
NY1002139OtherCDPHP
NY000401574001OtherBLUE SHIELD OF NENY
NY26210OtherMVP