Provider Demographics
NPI:1730105461
Name:AMBUSH, PAUL FRANKLIN JR (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:FRANKLIN
Last Name:AMBUSH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6030 DAYBREAK CIR STE A150
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1638
Mailing Address - Country:US
Mailing Address - Phone:410-531-7566
Mailing Address - Fax:410-531-9790
Practice Address - Street 1:11610 CLARKSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6142
Practice Address - Country:US
Practice Address - Phone:410-531-7566
Practice Address - Fax:410-531-9790
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0044955208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG777-0001OtherBLUECHOICE BC/BS MD
MD492666OtherNCPPO
MD8101718OtherMAMSI
MDKDV5PAOtherCAREFIRST BC/BS
MD2101718OtherALLIANCE
MD8101718OtherMDIPA
MD1203054OtherUNITED HEATH CARE
MD21394OtherPRIORITY PARTNERS
MD04134000000OtherPHN
MD152231100Medicaid
MD1808419OtherUNITED HEALTH CARE
MD5916668OtherAETNA, NON-HMO
MD2108817OtherAETNA, HMO
MD21394OtherEHP, JOHNS HOPKINS
MD8101718OtherOPTIMUM CHOICE
MDG777-0001OtherBLUECHOICE BC/BS MD