Provider Demographics
NPI:1497812010
Name:FERGUSON, R D (DO, PC)
Entity Type:Individual
Prefix:
First Name:R
Middle Name:D
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 MITCHELL PARK DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8965
Mailing Address - Country:US
Mailing Address - Phone:231-348-1968
Mailing Address - Fax:231-348-1969
Practice Address - Street 1:2390 MITCHELL PARK DR
Practice Address - Street 2:UNIT C
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8965
Practice Address - Country:US
Practice Address - Phone:231-348-1968
Practice Address - Fax:231-348-1969
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4830173Medicaid
MIG14045Medicare UPIN
MI4830173Medicaid