Provider Demographics
NPI:1124104765
Name:FERGUSON, MITZI GAIL (MD)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:GAIL
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5569
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39288-5569
Mailing Address - Country:US
Mailing Address - Phone:601-981-5887
Mailing Address - Fax:
Practice Address - Street 1:1991 LAKELAND DR STE C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5000
Practice Address - Country:US
Practice Address - Phone:601-981-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS092982080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122986Medicaid