Provider Demographics
NPI:1508880535
Name:FERGUSON, KEITH ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ANDREW
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198441 MBC-MMG
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:613 OAKFIELD DR
Practice Address - Street 2:TOWER DIAGNOSTIC CENTER
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5714
Practice Address - Country:US
Practice Address - Phone:813-661-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 898102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270713600Medicaid
FL48332ZMedicare ID - Type Unspecified