Provider Demographics
NPI:1780179929
Name:FERGIANI, KHADIJAH (MD)
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:
Last Name:FERGIANI
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1771
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN27510207Q00000X
FLME152700208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS421OtherMEDICARE HF
FL115413300Medicaid