Healthcare Provider Details

I. General information

NPI: 1841443306
Provider Name (Legal Business Name): JEFFERY ALBERT FERGERSON C.C.P., L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 11/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14603 HUEBNER RD BLG 28 STE 28101
SAN ANTONIO TX
78230-5469
US

IV. Provider business mailing address

14603 HUEBNER RD BLG 28 STE 28101
SAN ANTONIO TX
78230-5469
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-7074
  • Fax: 210-614-7091
Mailing address:
  • Phone: 210-614-7074
  • Fax: 210-614-7091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberPFO314
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: