Provider Demographics
NPI:1245330141
Name:FERGUSON, C. GLEN (DO)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:GLEN
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 BONFORTE BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1602
Mailing Address - Country:US
Mailing Address - Phone:719-296-5840
Mailing Address - Fax:
Practice Address - Street 1:1615 BONFORTE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1602
Practice Address - Country:US
Practice Address - Phone:719-296-5840
Practice Address - Fax:719-542-0746
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17205OtherCOLORADO STATE LICENSE
CO94559040Medicaid
CO01172055Medicaid
FE03792OtherBCBS
FE03792OtherBCBS
CO01172055Medicaid
COAF6168012OtherDEA