Provider Demographics
NPI:1215905591
Name:FERRIS, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:FERRIS
Suffix:
Gender:M
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 272
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-0272
Mailing Address - Country:US
Mailing Address - Phone:918-696-3101
Mailing Address - Fax:918-696-3388
Practice Address - Street 1:1401 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3217
Practice Address - Country:US
Practice Address - Phone:918-696-3101
Practice Address - Fax:918-696-3388
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1112696207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200062440AMedicaid
OK244531128Medicare ID - Type Unspecified
OK200062440AMedicaid