Provider Demographics
NPI:1447439872
Name:FERRIS, JOHN D (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:FERRIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3545
Mailing Address - Country:US
Mailing Address - Phone:307-856-0009
Mailing Address - Fax:
Practice Address - Street 1:300 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3545
Practice Address - Country:US
Practice Address - Phone:307-856-0009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2139A208D00000X
CO26101208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO89334841Medicaid
CO91021394Medicaid
KS0000563350OtherBC BS OF KS
WI830236758012OtherBCBS UNITED OF WISCONSIN
CO91021394Medicaid
WYD24749Medicare UPIN
CO89334841Medicaid