Provider Demographics
NPI:1144780958
Name:WAGLER, GORDON R (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:R
Last Name:WAGLER
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 1:104 LINER DR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2310
Mailing Address - Country:US
Mailing Address - Phone:864-227-1115
Mailing Address - Fax:864-227-2046
Practice Address - Street 1:104 LINER DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2310
Practice Address - Country:US
Practice Address - Phone:864-227-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC88395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine