1801823067 NPI number — KEVIN L FERGUSON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801823067 NPI number — KEVIN L FERGUSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
KEVIN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801823067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8139
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93403-8139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-541-6033
Provider Business Mailing Address Fax Number:
805-549-7463

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 E CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93454-5906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-548-1550
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ZH0000X , with the licence number:  A71757 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0105X , with the licence number: A71757 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A717570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0058760 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LAB43503F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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