Provider Demographics
NPI:1720216583
Name:FERGUSON, WILLIE (OD)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 NICHOLAS ST
Mailing Address - Street 2:STE 250
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9900 NICHOLAS ST
Practice Address - Street 2:SUITE 250
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-2249
Practice Address - Country:US
Practice Address - Phone:402-493-6500
Practice Address - Fax:402-493-4370
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1318152WP0200X, 152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy