Provider Demographics
NPI:1053361709
Name:FERGUSON, JOHN PAUL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
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 1:2831 FORT MISSOULA RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7419
Mailing Address - Country:US
Mailing Address - Phone:406-728-4601
Mailing Address - Fax:406-728-4604
Practice Address - Street 1:2831 FORT MISSOULA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-7419
Practice Address - Country:US
Practice Address - Phone:406-728-4601
Practice Address - Fax:406-728-4604
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4376174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0036803Medicaid
MT0036803Medicaid