Healthcare Provider Details

I. General information

NPI: 1831373414
Provider Name (Legal Business Name): DONALD FERGUSON JR. PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6062
US

IV. Provider business mailing address

PO BOX 699
MOUNTAIN HOME TN
37684-0699
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-6242
  • Fax:
Mailing address:
  • Phone: 423-433-6039
  • Fax: 423-433-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License NumberML7576
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: