Provider Demographics
NPI:1073678066
Name:WETHERINGTON, GARY MARC (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MARC
Last Name:WETHERINGTON
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0468
Mailing Address - Country:US
Mailing Address - Phone:706-291-4334
Mailing Address - Fax:706-291-0248
Practice Address - Street 1:506 RIVERSIDE PKWY NE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-2902
Practice Address - Country:US
Practice Address - Phone:706-291-4334
Practice Address - Fax:706-291-0248
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0306902086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000393137AMedicaid
GA000393137BMedicaid
D31314Medicare UPIN