Provider Demographics
NPI:1114304425
Name:FERGUSON, BREANNA J (DPM)
Entity Type:Individual
Prefix:DR
First Name:BREANNA
Middle Name:J
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 S DUNCAN DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4044
Mailing Address - Country:US
Mailing Address - Phone:352-432-8434
Mailing Address - Fax:
Practice Address - Street 1:870 S DUNCAN DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4044
Practice Address - Country:US
Practice Address - Phone:352-432-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4013213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist