MEDICARE: DR. GEORGE WORTHY PEGRAM III

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	0601001900	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	940935	OTHER	VA	EYEMED VISION CARE
2	5452	OTHER	VA	DAVIS VISION
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740264662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE WORTHY PEGRAM III

Provider Business Mailing Address
First Line	:	801 POINDEXTER ST STE 115
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2358
Country	:	US
Telephone Number	:	757-545-3930
Fax Number	:	757-545-0193

Provider Business Practice Location Address
First Line	:	801 POINDEXTER ST STE 115
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2358
Country	:	US
Telephone Number	:	757-545-3930
Fax Number	:	757-545-0193

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	09/13/2012

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