Provider Demographics
NPI:1093756678
Name:FERGUSON, SUSAN CALLAWAY (MD)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CALLAWAY
Last Name:FERGUSON
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 1:616 16TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND CA
Mailing Address - State:CA
Mailing Address - Zip Code:94612
Mailing Address - Country:US
Mailing Address - Phone:510-451-4270
Mailing Address - Fax:510-451-4285
Practice Address - Street 1:616 16TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612
Practice Address - Country:US
Practice Address - Phone:510-451-4270
Practice Address - Fax:510-451-4285
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68471207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI16659Medicare UPIN