Provider Demographics
NPI:1902425432
Name:SEAGRAVE, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SEAGRAVE
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 1:332 WORTHINGTON SQ
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2458
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2841 RENDOVA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-2111
Practice Address - Country:US
Practice Address - Phone:619-437-2860
Practice Address - Fax:619-437-2860
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN63518171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider