Provider Demographics
NPI:1851586804
Name:FERGUSON, CORY DAVID (DPT)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:DAVID
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N LITCHFIELD RD
Mailing Address - Street 2:STE. 155
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1333
Mailing Address - Country:US
Mailing Address - Phone:623-882-9787
Mailing Address - Fax:623-882-9791
Practice Address - Street 1:250 N LITCHFIELD RD
Practice Address - Street 2:STE. 155
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1333
Practice Address - Country:US
Practice Address - Phone:623-882-9787
Practice Address - Fax:623-882-9791
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00388070OtherRR MEDICARE
AZ64-0096OtherEVERCARE
AZ7499498OtherAETNA
AZ2Z2985OtherHEALTHNET
AZAZ0299850OtherBCBS
AZ0142085OtherDEPT OF LABOR
AZ103195OtherMEDICARE
AZ0142085OtherWASH DEPT OF LABOR
AZ6122OtherLICENSE #
AZ916190OtherAHCCCS
AZ916190OtherMERCY CARE PLAN