MEDICARE: GEORGE W. PEGRAM III, O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	0618000331	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083009039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGE W. PEGRAM III, O.D.

Provider Business Mailing Address
First Line	:	801 POINDEXTER ST
Second Line	:	STE 115
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2358
Country	:	US
Telephone Number	:	757-545-3930
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 POINDEXTER ST
Second Line	:	STE 115
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2358
Country	:	US
Telephone Number	:	757-545-3930
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GEORGE W. PEGRAM III
Credential	:	O.D.
Telephone Number	:	757-545-3930

Provider Enumeration Date	:	04/06/2015
Last Update Date	:	04/06/2015

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