Healthcare Provider Details

I. General information

NPI: 1780669267
Provider Name (Legal Business Name): DERRON WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13345 ILLINOIS ST
CARMEL IN
46032-3318
US

IV. Provider business mailing address

13345 ILLINOIS ST
CARMEL IN
46032-3318
US

V. Phone/Fax

Practice location:
  • Phone: 317-396-1300
  • Fax: 317-870-2728
Mailing address:
  • Phone: 317-396-1300
  • Fax: 317-870-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number01047150A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: