Provider Demographics
NPI:1447294384
Name:FERGUSON, DIANE MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-2412
Mailing Address - Country:US
Mailing Address - Phone:310-418-3266
Mailing Address - Fax:
Practice Address - Street 1:502 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3413
Practice Address - Country:US
Practice Address - Phone:310-792-3647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG079787207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine