Provider Demographics
NPI:1497731343
Name:PEARSON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PEARSON
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:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0623
Mailing Address - Country:US
Mailing Address - Phone:434-584-2273
Mailing Address - Fax:434-584-5579
Practice Address - Street 1:1755 N MECKLENBURG AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-4080
Practice Address - Country:US
Practice Address - Phone:434-584-2273
Practice Address - Fax:434-584-5579
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86658208800000X
VA0101270400208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOJC64OtherBCBSFL
GA003131436AMedicaid
GA2021346041OtherTRICARE
FLOJC64OtherBCBSFL
GA303541800OtherUS DOL
GA01768127OtherAMERIGROUP
GA215163OtherWELLCARE
GA0438940001OtherPALMETTO
GA303541800OtherUS DOL
GA215163OtherWELLCARE