Provider Demographics
NPI:1205858222
Name:WILSON, PAUL G
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 KING JOHN DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2397
Mailing Address - Country:US
Mailing Address - Phone:317-782-4820
Mailing Address - Fax:
Practice Address - Street 1:7910 E WASHINGTON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-6803
Practice Address - Country:US
Practice Address - Phone:317-355-7171
Practice Address - Fax:317-355-9022
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029579A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100072620Medicaid
IN000000312971OtherANTHEM
INP00261923OtherRR MEDICARE
INC24428Medicare UPIN
INP00261923OtherRR MEDICARE
INM400037986Medicare PIN
INM400037990Medicare PIN