Provider Demographics
NPI:1477998664
Name:PEMBERTON, WILLIAM BLAKE (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BLAKE
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 TOWNE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-8910
Mailing Address - Country:US
Mailing Address - Phone:919-859-3373
Mailing Address - Fax:919-336-4363
Practice Address - Street 1:1010 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2507
Practice Address - Country:US
Practice Address - Phone:919-690-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142310207P00000X
NC2015-01934207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL2853OtherFL MEDICARE