Provider Demographics
NPI:1750592101
Name:FERGUSON, MICHAEL THOMAS (OD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2146 COVEBOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405
Mailing Address - Country:US
Mailing Address - Phone:850-769-4040
Mailing Address - Fax:850-769-4411
Practice Address - Street 1:2146 N COVE BLVD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-5319
Practice Address - Country:US
Practice Address - Phone:850-769-4040
Practice Address - Fax:850-769-4411
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10047OtherNVA
FL10451OtherSVS FORD
FL2449OtherDAVIS
FL05113OtherSPECTARA
FL38742OtherAVESIS