Provider Demographics
NPI:1154309466
Name:FERGUSON, KEENAN L (DO)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:L
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-2448
Mailing Address - Country:US
Mailing Address - Phone:580-596-2800
Mailing Address - Fax:580-596-2805
Practice Address - Street 1:405 S OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:CHEROKEE
Practice Address - State:OK
Practice Address - Zip Code:73728-2545
Practice Address - Country:US
Practice Address - Phone:580-596-2800
Practice Address - Fax:580-596-2805
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200088860AMedicaid
I15054Medicare UPIN
OK244628302Medicare ID - Type Unspecified