Provider Demographics
NPI:1922063734
Name:FERGUSON, TRACY (MD)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:FERGUSON
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 1:4112 E PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-8106
Mailing Address - Country:US
Mailing Address - Phone:404-296-7133
Mailing Address - Fax:404-296-7211
Practice Address - Street 1:4112 E PONCE DE LEON AVE
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-8106
Practice Address - Country:US
Practice Address - Phone:404-296-7133
Practice Address - Fax:404-296-7211
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054023208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA347582150AMedicaid
GA347582150BMedicaid