Provider Demographics
NPI:1528157930
Name:FERGUSON, JOHN VAUGHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:VAUGHN
Last Name:FERGUSON
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 1:169 LAURELHURST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-3825
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:
Practice Address - Street 1:2117 GERVAIS ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1805
Practice Address - Country:US
Practice Address - Phone:803-744-0540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10102207V00000X
NC24590207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC31627OtherBLUE CROSS BLUE SHIELD
NC1528157930Medicaid
SC101026Medicaid
206248DOtherMEDICARE INDIVIDUAL PTAN LINKED TO FACULTY PRACTICE GROUP
NCC83740Medicare UPIN