Healthcare Provider Details

I. General information

NPI: 1215007125
Provider Name (Legal Business Name): KERON ALICIA FERGUSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MAITLAND CENTER PKWY STE 310
MAITLAND FL
32751-7442
US

IV. Provider business mailing address

222 BROADWAY SUITE 301 ATTN: CREDENTIALING
KISSIMMEE FL
34741
US

V. Phone/Fax

Practice location:
  • Phone: 407-426-4800
  • Fax: 407-426-4820
Mailing address:
  • Phone: 407-846-8180
  • Fax: 800-517-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME94429
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME94429
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberME94429
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: