Provider Demographics
NPI:1801823067
Name:FERGUSON, KEVIN L (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
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:PO BOX 8139
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-8139
Mailing Address - Country:US
Mailing Address - Phone:805-541-6033
Mailing Address - Fax:805-549-7463
Practice Address - Street 1:1400 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5906
Practice Address - Country:US
Practice Address - Phone:805-548-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71757207ZH0000X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A717570Medicaid
CAGR0058760Medicaid
CALAB43503FMedicaid
CAH83641Medicare UPIN
CAWA71757AMedicare ID - Type UnspecifiedINDIVIDUAL
CAGR0058760Medicaid
CALAB43503FMedicaid