Provider Demographics
NPI:1083009039
Name:GEORGE W. PEGRAM III, O.D.
Entity Type:Organization
Organization Name:GEORGE W. PEGRAM III, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEGRAM
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:757-545-3930
Mailing Address - Street 1:801 POINDEXTER ST
Mailing Address - Street 2:STE 115
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-2358
Mailing Address - Country:US
Mailing Address - Phone:757-545-3930
Mailing Address - Fax:
Practice Address - Street 1:801 POINDEXTER ST
Practice Address - Street 2:STE 115
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-2358
Practice Address - Country:US
Practice Address - Phone:757-545-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740264662Medicaid