Provider Demographics
NPI:1568461564
Name:PEDERSEN, WILLIAM R (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 W LAMAR ALEXANDER PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-3900
Mailing Address - Country:US
Mailing Address - Phone:865-982-2020
Mailing Address - Fax:865-970-2020
Practice Address - Street 1:730 W LAMAR ALEXANDER PKWY
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3900
Practice Address - Country:US
Practice Address - Phone:865-982-2020
Practice Address - Fax:865-970-2020
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
602004601OtherCARITEN
620927830OtherUNITED HEALTHCARE
TN2005369OtherBLUE CROSS BLUE SHIELD
620927830OtherCIGNA
TN410014914Medicare PIN
TNT61145Medicare UPIN
620927830OtherCIGNA
TN3593619Medicare PIN