Provider Demographics
NPI:1447273677
Name:FERGUSON, AMY S (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:S
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MEDICAL DR.
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006
Mailing Address - Country:US
Mailing Address - Phone:830-331-8981
Mailing Address - Fax:830-331-8983
Practice Address - Street 1:104 MEDICAL DR.
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:830-331-8981
Practice Address - Fax:830-331-8983
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6852TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V10993Medicare UPIN
8G8690Medicare PIN