Provider Demographics
NPI:1770532525
Name:GWYNETTE, GRETCHEN WRISTON (MD)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:WRISTON
Last Name:GWYNETTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:ANN
Other - Last Name:WRISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1394 CENTER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7420
Mailing Address - Country:US
Mailing Address - Phone:843-475-4325
Mailing Address - Fax:
Practice Address - Street 1:1394 CENTER LAKE DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7420
Practice Address - Country:US
Practice Address - Phone:843-475-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA782962085R0202X
SC303362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A782960Medicaid
CAWA78296BMedicare PIN
CA35606Medicare UPIN
CAWA78296AMedicare PIN