Healthcare Provider Details

I. General information

NPI: 1912355330
Provider Name (Legal Business Name): KYLE C WILMES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 N 5TH ST
TERRE HAUTE IN
47804-4010
US

IV. Provider business mailing address

1606 N 7TH ST
TERRE HAUTE IN
47804-2706
US

V. Phone/Fax

Practice location:
  • Phone: 812-242-3005
  • Fax: 812-242-3054
Mailing address:
  • Phone: 812-238-4989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001380A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: