Provider Demographics
NPI:1518962968
Name:FERGUSON, CLAY WALT (MD)
Entity Type:Individual
Prefix:DR
First Name:CLAY
Middle Name:WALT
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 522
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-0522
Mailing Address - Country:US
Mailing Address - Phone:870-845-0033
Mailing Address - Fax:870-451-9878
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-2001
Practice Address - Country:US
Practice Address - Phone:870-845-0033
Practice Address - Fax:870-451-9878
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8428207Q00000X
TNMD0000031428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR080158965OtherRAILROAD MEDICARE
AR5K772OtherBLUE CROSS BLUE SHIELD
AR2110031500OtherQUAL CHOICE
AR134714001Medicaid
ARBF5895620OtherDEA
AR5K772Medicare PIN
ARG69138Medicare UPIN