Provider Demographics
NPI:1134656853
Name:FERGUSON, DERRICK T (DO)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:T
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:DERRICK
Other - Middle Name:T
Other - Last Name:WALLACE-FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-331-3400
Practice Address - Fax:812-332-7265
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02007001A207R00000X, 207RP1001X, 207RC0200X
MI5101023275207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300078836Medicaid
IN090540882OtherMEDICARE PTAN