Healthcare Provider Details

I. General information

NPI: 1306800453
Provider Name (Legal Business Name): FERGUS COAKLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD OHSU
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD OHSU
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-2333
  • Fax: 503-494-4982
Mailing address:
  • Phone: 503-494-2333
  • Fax: 503-494-4982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberMD158521
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD158521
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: