Provider Demographics
NPI:1396847539
Name:WEISGERBER, MICHAEL P (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:WEISGERBER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 EPPS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2449
Mailing Address - Country:US
Mailing Address - Phone:843-374-5487
Mailing Address - Fax:843-374-7342
Practice Address - Street 1:123 EPPS ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2449
Practice Address - Country:US
Practice Address - Phone:843-374-5487
Practice Address - Fax:843-374-7342
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1933152W00000X
MI4901003653152WP0200X, 152WS0006X, 152WX0102X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP30340003Medicare PIN