Provider Demographics
NPI:1104067909
Name:FERGUSON, ANGELA GREMILLION (DO)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:GREMILLION
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:9812 SLIDE RD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5781
Practice Address - Country:US
Practice Address - Phone:806-725-8765
Practice Address - Fax:806-725-8758
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7436207R00000X
NMA-1661-12207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83308539Medicaid
TX8DY748OtherBCBS TX
TX960091100OtherFIRSTCARE
TX326015001Medicaid
TX8DY748OtherBCBS TX