Healthcare Provider Details

I. General information

NPI: 1699035030
Provider Name (Legal Business Name): THEODORE ERNEST WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6789
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-0850
  • Fax: 502-588-0861
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01079354A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number01079354A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP27658
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberTP230
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: