Healthcare Provider Details

I. General information

NPI: 1700415791
Provider Name (Legal Business Name): CONNOR WAYDE FERGUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 ABERDEEN BLVD
GASTONIA NC
28054-0624
US

IV. Provider business mailing address

2325 ABERDEEN BLVD
GASTONIA NC
28054-0624
US

V. Phone/Fax

Practice location:
  • Phone: 704-853-3937
  • Fax: 704-853-8029
Mailing address:
  • Phone: 704-853-3937
  • Fax: 704-853-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2024-00411
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: