Provider Demographics
NPI:1770550337
Name:MARKHAM, GEORGE L III (PAC)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:L
Last Name:MARKHAM
Suffix:III
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6632 INDIAN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-3442
Mailing Address - Country:US
Mailing Address - Phone:757-424-4300
Mailing Address - Fax:757-523-0632
Practice Address - Street 1:3241 WESTERN BRANCH BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5260
Practice Address - Country:US
Practice Address - Phone:757-686-3508
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008951349Medicaid
000334S33Medicare ID - Type Unspecified
VA008951349Medicaid