Provider Demographics
NPI:1265525331
Name:FERGUSON, DIANE A (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:A
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2085 GOODMAN RD W
Mailing Address - Street 2:SUITE 50
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1416
Mailing Address - Country:US
Mailing Address - Phone:662-253-8459
Mailing Address - Fax:662-253-8678
Practice Address - Street 1:2085 GOODMAN RD W
Practice Address - Street 2:SUITE 50
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1416
Practice Address - Country:US
Practice Address - Phone:662-253-8459
Practice Address - Fax:662-253-8678
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-05-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS10806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0111871Medicaid
MS0111871Medicaid
MSB30199Medicare UPIN