Provider Demographics
NPI:1902123102
Name:FURGERSON, MARY CATHERINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:CATHERINE
Last Name:FURGERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-1178
Mailing Address - Country:US
Mailing Address - Phone:614-879-7239
Mailing Address - Fax:614-879-1001
Practice Address - Street 1:487 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-1178
Practice Address - Country:US
Practice Address - Phone:614-879-7239
Practice Address - Fax:614-879-1001
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5927152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0009987600OtherAETNA: PIN #
OH020700417050OtherCARESOURCE
OH3047394Medicaid
OH4292201Medicare PIN