Healthcare Provider Details

I. General information

NPI: 1619068681
Provider Name (Legal Business Name): CARL EDWARD FERGUSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/17/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3514 N POWER RD STE 105
MESA AZ
85215-2907
US

IV. Provider business mailing address

7529 E BASELINE SUITE 101
MESA AZ
85208
US

V. Phone/Fax

Practice location:
  • Phone: 480-422-8533
  • Fax: 480-981-2442
Mailing address:
  • Phone: 480-945-4343
  • Fax: 480-945-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2244
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: