Provider Demographics
NPI:1982886925
Name:FERGUSON, DELORES
Entity Type:Individual
Prefix:MRS
First Name:DELORES
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DEE
Other - Middle Name:
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WIG EXPERT COSMOTOL
Mailing Address - Street 1:9555 LEBANON RD
Mailing Address - Street 2:102
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-6095
Mailing Address - Country:US
Mailing Address - Phone:903-821-1875
Mailing Address - Fax:
Practice Address - Street 1:104 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WHITESBORO
Practice Address - State:TX
Practice Address - Zip Code:76273-2202
Practice Address - Country:US
Practice Address - Phone:903-821-1875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-01
Last Update Date:2007-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX887136335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier