Basic Information
Provider Information
NPI: 1033557996
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FERGUSON
FirstName: JOHN
MiddleName: DAVID
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: HC 60 BOX 580
Address2:  
City: HAWORTH
State: OK
PostalCode: 747409609
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 15481 N JARVIS RD
Address2:  
City: TAHLEQUAH
State: OK
PostalCode: 744640233
CountryCode: US
TelephoneNumber: 9184565131
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/12/2013
LastUpdateDate: 06/12/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171W00000X  Y Other Service ProvidersContractor 

No ID Information.


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