Provider Demographics
NPI:1811999717
Name:FERGUSON, BRUCE L
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:L
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 S PALM CANYON DR BLDG C
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-8354
Mailing Address - Country:US
Mailing Address - Phone:760-969-7770
Mailing Address - Fax:760-969-7771
Practice Address - Street 1:1555 S PALM CANYON DR BLDG C
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-8354
Practice Address - Country:US
Practice Address - Phone:760-969-7770
Practice Address - Fax:760-969-7771
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088421207R00000X
CAG89429207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01615327OtherBLUE CROSS
IL036088421Medicaid
F78057Medicare UPIN
IL01615327OtherBLUE CROSS