Provider Demographics
NPI:1861560021
Name:FERGUSON, DAWN CAMILLE (MD)
Entity type:Individual
Prefix:MISS
First Name:DAWN
Middle Name:CAMILLE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 FOX ST SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2942
Mailing Address - Country:US
Mailing Address - Phone:770-634-6332
Mailing Address - Fax:
Practice Address - Street 1:311 WHITE INGRAM PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-0969
Practice Address - Country:US
Practice Address - Phone:678-647-9947
Practice Address - Fax:678-363-7787
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0351792083A0300X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000616932EMedicaid
GA000616932EMedicaid
GA70075Medicare UPIN