Provider Demographics
NPI:1609989250
Name:FERGUSON, SUSAN PORTIS (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PORTIS
Last Name:FERGUSON
Suffix:
Gender:F
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 800
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:AR
Mailing Address - Zip Code:72744-0810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 E PARK ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:AR
Practice Address - Zip Code:72744-8706
Practice Address - Country:US
Practice Address - Phone:479-267-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131505001Medicaid
080127088OtherRAILROAD MEDICARE
080127088OtherRAILROAD MEDICARE
AR131505001Medicaid