Provider Demographics
NPI:1649702150
Name:FERGUSON, DEANGELO HEASTON (MBBS)
Entity type:Individual
Prefix:DR
First Name:DEANGELO
Middle Name:HEASTON
Last Name:FERGUSON
Suffix:
Gender:
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2689
Mailing Address - Country:US
Mailing Address - Phone:313-916-6374
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2689
Practice Address - Country:US
Practice Address - Phone:313-916-6374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2025-04-17
Deactivation Date:2017-12-07
Deactivation Code:
Reactivation Date:2017-12-07
Provider Licenses
StateLicense IDTaxonomies
KS04-050630208200000X
390200000X
MI4351048917208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program