Provider Demographics
NPI:1013082452
Name:FERGUSON, RENA K (MD)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:K
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 1:128 OLD TOWN ROAD
Mailing Address - Street 2:STE C & D
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-689-5390
Mailing Address - Fax:631-689-5395
Practice Address - Street 1:128 OLD TOWN ROAD
Practice Address - Street 2:STE C & D
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-689-5390
Practice Address - Fax:631-689-5395
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2303302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02501137Medicaid
NY388BK1Medicare PIN
I01856Medicare UPIN