Provider Demographics
NPI:1720198963
Name:FERGUSON, RICKY CARROLL (OD)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:CARROLL
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 1:408 W MCCLOY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655
Mailing Address - Country:US
Mailing Address - Phone:870-367-8511
Mailing Address - Fax:870-367-3215
Practice Address - Street 1:408 W MCCLOY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-367-8511
Practice Address - Fax:870-367-3215
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2309152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR410040927OtherRAILROAD MEDICARE
AR102151722Medicaid
T20324Medicare UPIN
AR49538Medicare ID - Type Unspecified
AR410040927OtherRAILROAD MEDICARE