Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0007X | Plastic Surgeon (Head & Neck) | 036078516 | IL |
NPI | 1669452934 |
---|---|
Provider Name | Jonathan L. Ferguson |
First Address | Rockford, IL 61107-6303 |
Second Address | Rockford, IL 61107-6303 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2006 |
Last Update Date | 21/09/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036078516 | (05) | IL |
E18270 | (02) | IL |