Provider Demographics
NPI:1760485494
Name:FERGUSON, EARL W (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:W
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 1:1539 N CHINA LAKE BLVD
Mailing Address - Street 2:# A
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2606
Mailing Address - Country:US
Mailing Address - Phone:760-499-3454
Mailing Address - Fax:760-446-2254
Practice Address - Street 1:1081 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-499-3000
Practice Address - Fax:760-499-3014
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83290174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-2082686OtherTAX ID
CAG83290OtherMEDICAL LICENSE
CA00G832900Medicaid
CA00G832900Medicaid
CA95-2082686OtherTAX ID