MEDICARE: DR. MARK EDWARD FERGUSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046008331	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598897456
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK EDWARD FERGUSON O.D.

Provider Business Mailing Address
First Line	:	40 KINGSLEY WAY
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-1548
Country	:	US
Telephone Number	:	618-288-7350
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2558
Country	:	US
Telephone Number	:	618-466-8787
Fax Number	:	618-466-4703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	09/02/2010

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