Provider Demographics
NPI:1740264662
Name:PEGRAM, GEORGE WORTHY III
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WORTHY
Last Name:PEGRAM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 POINDEXTER ST STE 115
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23324-2358
Mailing Address - Country:US
Mailing Address - Phone:757-545-3930
Mailing Address - Fax:757-545-0193
Practice Address - Street 1:801 POINDEXTER ST STE 115
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23324-2358
Practice Address - Country:US
Practice Address - Phone:757-545-3930
Practice Address - Fax:757-545-0193
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601001900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA940935OtherEYEMED VISION CARE
VA5452OtherDAVIS VISION
VA009238182Medicaid
VA940935OtherEYEMED VISION CARE
VA009238182Medicaid