Provider Demographics
NPI:1134142300
Name:WANNER, MATTHEW R (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:WANNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-715-6402
Mailing Address - Fax:
Practice Address - Street 1:1125 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-2140
Practice Address - Country:US
Practice Address - Phone:317-472-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010552812085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00319271OtherRAILROAD MEDICARE
IN200526920Medicaid
IN959090T2Medicare PIN
INI35098Medicare UPIN
IN200526920Medicaid