Provider Demographics
NPI:1356306740
Name:FERGUISON, KIMBERLY D (MD-PEDIATRICS)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:D
Last Name:FERGUISON
Suffix:
Gender:F
Credentials:MD-PEDIATRICS
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:D
Other - Last Name:GRANWEHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:3280 E LANARK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5982
Practice Address - Country:US
Practice Address - Phone:208-377-4400
Practice Address - Fax:208-377-4416
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9507208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID76552OtherBLUE CROSS
ID000010154462OtherBLUE SHIELD
ID807392600OtherHEALTHY CONNECTIONS MCAID
ID807354800Medicaid
ID76552OtherBLUE CROSS
ID000010154462OtherBLUE SHIELD