Basic Information
| Provider Information | |||||||||
| NPI: | 1306800453 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COAKLEY | ||||||||
| FirstName: | FERGUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | OHSU | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034942333 | ||||||||
| FaxNumber: | 5034944982 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | OHSU | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034942333 | ||||||||
| FaxNumber: | 5034944982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 01/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | MD158521 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | MD158521 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A695760 | 05 | CA | MEDICAID |