Basic Information
| Provider Information | |||||||||
| NPI: | 1508857764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2505 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122387783 | ||||||||
| FaxNumber: | 8122384506 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 LANKFORD ST | ||||||||
| Address2: | |||||||||
| City: | CLAY CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478411008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129392126 | ||||||||
| FaxNumber: | 8129393414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 10/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01043986 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00213807 | 01 | IN | RR MEDICARE | OTHER | 100369360 | 05 | IN | MEDICAID |