Provider Demographics
NPI:1205878451
Name:FERGUSON, TIMOTHY J (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S GRAND AVE
Mailing Address - Street 2:GLENDORA
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-4205
Mailing Address - Country:US
Mailing Address - Phone:626-335-3527
Mailing Address - Fax:626-963-7972
Practice Address - Street 1:210 S. GRAND
Practice Address - Street 2:GLENDORA
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4205
Practice Address - Country:US
Practice Address - Phone:626-963-9402
Practice Address - Fax:626-914-5316
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA036813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0023980Medicaid
CAA28186Medicare UPIN
CAWA36813AMedicare PIN