Provider Demographics
NPI:1043666191
Name:FERGUSON, ETHAN L (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:L
Last Name:FERGUSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 N SENATE BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1260
Mailing Address - Country:US
Mailing Address - Phone:317-962-3700
Mailing Address - Fax:317-962-2893
Practice Address - Street 1:1801 N SENATE BLVD SUITE 220
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-3700
Practice Address - Fax:317-962-2893
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-08
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.142317208800000X
IN01090971A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1102510313OtherANTHEM PTAN
IN300078672Medicaid