Provider Demographics
NPI:1295774131
Name:JETER, WILLIAM RICHARD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:JETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1800 GLENSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:1800 GLENSIDE DR
Practice Address - Street 2:STE 110
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3769
Practice Address - Country:US
Practice Address - Phone:804-288-1800
Practice Address - Fax:804-288-0515
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101027773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005635497Medicaid
VA141472OtherANTHEM
VA080182274OtherRAILROAD MEDICARE
VA080182274OtherRAILROAD MEDICARE