Healthcare Provider Details

I. General information

NPI: 1942259676
Provider Name (Legal Business Name): MICHAEL J WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

IV. Provider business mailing address

3401 E RAYMOND ST
INDIANAPOLIS IN
46203-4744
US

V. Phone/Fax

Practice location:
  • Phone: 317-488-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01058771A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01058771A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: