Provider Demographics
NPI:1205128352
Name:PEGRAM, TREY AMERSON (MD)
Entity type:Individual
Prefix:MR
First Name:TREY
Middle Name:AMERSON
Last Name:PEGRAM
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 1:306 LANDRUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4648
Mailing Address - Country:US
Mailing Address - Phone:931-221-9544
Mailing Address - Fax:931-444-5111
Practice Address - Street 1:306 LANDRUM PLACE
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4648
Practice Address - Country:US
Practice Address - Phone:931-221-9544
Practice Address - Fax:931-444-5111
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD-55555207WX0200X
TXQ2364207W00000X
TNTN-55555207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ029682Medicaid