Provider Demographics
NPI:1669452934
Name:FERGUSON, JONATHAN L (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
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 1:698 FEATHERSTONE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6303
Mailing Address - Country:US
Mailing Address - Phone:815-398-3277
Mailing Address - Fax:815-484-7001
Practice Address - Street 1:698 FEATHERSTONE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6303
Practice Address - Country:US
Practice Address - Phone:815-398-3277
Practice Address - Fax:815-484-7001
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078516207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036078516Medicaid
K45226Medicare PIN
ILE18270Medicare UPIN