Provider Demographics
NPI:1063682383
Name:WILLIAM R PEDERSEN
Entity Type:Organization
Organization Name:WILLIAM R PEDERSEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:865-982-2020
Mailing Address - Street 1:730 WEST LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801
Mailing Address - Country:US
Mailing Address - Phone:865-982-2020
Mailing Address - Fax:865-970-2020
Practice Address - Street 1:730 WEST LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801
Practice Address - Country:US
Practice Address - Phone:865-982-2020
Practice Address - Fax:865-970-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0175360001Medicare NSC