Provider Demographics
NPI:1619068681
Name:FERGUSON, CARL EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:EDWARD
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5416 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-4700
Mailing Address - Country:US
Mailing Address - Phone:480-945-4343
Mailing Address - Fax:480-945-4350
Practice Address - Street 1:3514 N POWER RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2907
Practice Address - Country:US
Practice Address - Phone:480-422-8533
Practice Address - Fax:480-981-2442
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00195445OtherMEDICARE RR
AZ273665Medicaid
AZAZ0730610OtherBCBS
C98223Medicare UPIN