Provider Demographics
NPI:1801837968
Name:WEATHERS, WILLIAM TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TRAVIS
Last Name:WEATHERS
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:1650 SKYN DRIVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1069
Practice Address - Country:US
Practice Address - Phone:864-598-0460
Practice Address - Fax:864-596-5164
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5116208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863032OtherBCBS OF SC ID
SC051160Medicaid
SC6356292OtherCIGNA ID
SCC606906904Medicare ID - Type UnspecifiedMEDICARE ID
SC051160Medicaid