Provider Demographics
NPI:1538697537
Name:FERGUSON, JORDAN BLAKE (DO)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:BLAKE
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 RILEY HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5109
Mailing Address - Country:US
Mailing Address - Phone:317-944-5000
Mailing Address - Fax:
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-5000
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014921208000000X
IAR-10953208000000X
IADO-05346208000000X
IN02007657A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300090157Medicaid
IN1101473792OtherANTHEM PTAN