Healthcare Provider Details

I. General information

NPI: 1558725937
Provider Name (Legal Business Name): GREGORY PEARSON WYNNE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9669 E 146TH ST STE 330
NOBLESVILLE IN
46060-5006
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-2663
  • Fax:
Mailing address:
  • Phone: 317-621-1647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02006722A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number02006722A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: