Provider Demographics
NPI:1174698351
Name:FURGURSON, JILL E (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:E
Last Name:FURGURSON
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 1:23941 DE VILLE WAY
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4894
Mailing Address - Country:US
Mailing Address - Phone:310-456-3036
Mailing Address - Fax:310-456-2451
Practice Address - Street 1:147 N BRENT ST
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2809
Practice Address - Country:US
Practice Address - Phone:805-652-5051
Practice Address - Fax:805-585-3007
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36815146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSC30394FMedicaid
CAZZZ53994ZOtherBLUE SHIELD
CA050394OtherBLUE CROSS
CAZZZA56032OtherBLUE SHIELD
CA95-1683892OtherOTHER INSURANCE
CAZZT40394FMedicaid
CAZZZ53994ZOtherBLUE SHIELD
CAZZT40394FMedicaid