Individual
DERRICK T FERGUSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
2651 E DISCOVERY PKWY, BLOOMINGTON, IN 47408-9059
(812) 331-3400
(812) 332-7265
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
02007001A
IN
207R00000X
Internal Medicine Physician
5101023275
MI
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
02007001A
IN
207RP1001X
Pulmonary Disease Physician
02007001A
IN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
090540882
MEDICARE PTAN
IN
05
—
300078836
—
IN
Enumeration date
05/12/2017
Last updated
10/18/2023
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