Provider Demographics
NPI:1215013297
Name:FERGUSON, OTIS B III (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:B
Last Name:FERGUSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7633 E JEFFERSON
Mailing Address - Street 2:STE 120
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3730
Mailing Address - Country:US
Mailing Address - Phone:313-824-8941
Mailing Address - Fax:313-824-1115
Practice Address - Street 1:7633 E JEFFERSON
Practice Address - Street 2:STE 120
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3730
Practice Address - Country:US
Practice Address - Phone:313-824-8941
Practice Address - Fax:313-824-1115
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301064409207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000002337OtherCAPE HEALTH PLAN
5285466OtherAETNA
48637OtherOMNICARE
1808205190OtherBCBS
1004844002OtherWELLNESS PLAN
117351OtherCARE CHOICES
G12616OtherHAP
117351OtherCARE CHOICES
1169640001Medicare NSC