Provider Demographics
NPI:1740303841
Name:FERGUSON, DOUGLAS HOWARD (SPEECH LANGUAGE PATH)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HOWARD
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 DE PAOLI RD
Mailing Address - Street 2:
Mailing Address - City:HOLTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92250-9500
Mailing Address - Country:US
Mailing Address - Phone:760-344-5431
Mailing Address - Fax:760-344-8240
Practice Address - Street 1:120 W COLE RD
Practice Address - Street 2:SUITE B
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-9700
Practice Address - Country:US
Practice Address - Phone:760-344-5431
Practice Address - Fax:760-344-8240
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP1975235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP1975Medicare UPIN