Provider Demographics
NPI:1770558561
Name:PEGRAM & CORNETTA P L C
Entity type:Organization
Organization Name:PEGRAM & CORNETTA P L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:CORNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-622-5595
Mailing Address - Street 1:1900 COLLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1613
Mailing Address - Country:US
Mailing Address - Phone:757-622-5595
Mailing Address - Fax:
Practice Address - Street 1:1900 COLLEY AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1613
Practice Address - Country:US
Practice Address - Phone:757-622-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5478680001Medicare NSC
VAC05876Medicare PIN