Healthcare Provider Details

I. General information

NPI: 1689805061
Provider Name (Legal Business Name): FREDERICKA ALONA WILSON DPM, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 86TH ST STE A
INDIANAPOLIS IN
46268-1779
US

IV. Provider business mailing address

8206 ROCKVILLE RD # 192
INDIANAPOLIS IN
46214-3113
US

V. Phone/Fax

Practice location:
  • Phone: 317-872-3338
  • Fax: 317-872-3339
Mailing address:
  • Phone: 317-872-3338
  • Fax: 317-872-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number07001094A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: