Provider Demographics
NPI:1043259104
Name:FERGUSON, THOMAS R (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:R
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 1:2510 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7546
Mailing Address - Country:US
Mailing Address - Phone:406-721-5925
Mailing Address - Fax:406-721-3859
Practice Address - Street 1:2510 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-7546
Practice Address - Country:US
Practice Address - Phone:406-721-5925
Practice Address - Fax:406-721-3859
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT387152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT482053Medicaid
MT482053Medicaid