MEDICARE: DR. WILLIAM EMMETT JEFFERSON III MD

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	0101042761	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	220030578	OTHER		RAILROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1275532236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM EMMETT JEFFERSON III MD

Provider Business Mailing Address
First Line	:	1 RIVERSIDE CIR
Second Line	:	SUITE 105
City	:	ROANOKE
State	:	VA
Zip	:	24016-4961
Country	:	US
Telephone Number	:	540-581-0150
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 RIVERSIDE CIR
Second Line	:	SUITE 105
City	:	ROANOKE
State	:	VA
Zip	:	24016-4961
Country	:	US
Telephone Number	:	540-581-0150
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	05/26/2016

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