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General NPI Number Information
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NPI Number | 1720154057
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Entity Type | Organization
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Legal Business Name | GEORGE W. PEGRAM III
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Dates
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Enumeration Date | 11/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1109 POINDEXTER ST
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City | CHESAPEAKE
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State | VA
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Zip | 23324-2424
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Country | US
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Telephone | 757-545-3930
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Fax | 757-545-0193
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Provider Business Mailing Address
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Address Line | 1109 POINDEXTER ST
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City | CHESAPEAKE
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State | VA
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Zip | 23324-2424
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Country | US
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Telephone | 757-545-3930
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Fax | 757-545-0193
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Authorized Official
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Title or Position | OWNER
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Name | DR. GEORGE WORTHY PEGRAM III
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Credential | O.D.
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Telephone | 757-545-3930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618000331
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License Number State | VA
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