Provider Demographics
NPI:1598897456
Name:FERGUSON, MARK EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWARD
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 KINGSLEY WAY
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1548
Mailing Address - Country:US
Mailing Address - Phone:618-288-7350
Mailing Address - Fax:
Practice Address - Street 1:3300 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2558
Practice Address - Country:US
Practice Address - Phone:618-466-8787
Practice Address - Fax:618-466-4703
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008331Medicaid
ILU09739Medicare UPIN
ILK49535Medicare PIN
IL046008331Medicaid