Healthcare Provider Details

I. General information

NPI: 1154309466
Provider Name (Legal Business Name): KEENAN L FERGUSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 S OKLAHOMA AVE
CHEROKEE OK
73728-2545
US

IV. Provider business mailing address

900 17TH ST
WOODWARD OK
73801-2448
US

V. Phone/Fax

Practice location:
  • Phone: 580-596-2800
  • Fax: 580-596-2805
Mailing address:
  • Phone: 580-596-2800
  • Fax: 580-596-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4405
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: