Healthcare Provider Details

I. General information

NPI: 1144780958
Provider Name (Legal Business Name): GORDON R WAGLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LINER DR
GREENWOOD SC
29646-2310
US

IV. Provider business mailing address

104 LINER DR
GREENWOOD SC
29646-2310
US

V. Phone/Fax

Practice location:
  • Phone: 864-227-1115
  • Fax:
Mailing address:
  • Phone: 864-227-1115
  • Fax: 864-227-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number88395
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: