Provider Demographics
NPI:1093768616
Name:WEIGLE, GORDON REESE II (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:REESE
Last Name:WEIGLE
Suffix:II
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 1218
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-5218
Mailing Address - Country:US
Mailing Address - Phone:803-635-6461
Mailing Address - Fax:803-635-4200
Practice Address - Street 1:880 W MOULTRIE ST STE 200
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-2411
Practice Address - Country:US
Practice Address - Phone:803-635-6461
Practice Address - Fax:803-635-4200
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC8901207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC089013Medicaid
SC089013Medicaid
SC3426Medicare PIN
SCD178417659Medicare PIN