Provider Demographics
NPI:1417995135
Name:WEDLOCK, STINA (MD)
Entity Type:Individual
Prefix:
First Name:STINA
Middle Name:
Last Name:WEDLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W RAMPART ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-8846
Mailing Address - Country:US
Mailing Address - Phone:317-421-2012
Mailing Address - Fax:317-398-1851
Practice Address - Street 1:2451 INTELLIPLEX DR STE 260
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8580
Practice Address - Country:US
Practice Address - Phone:317-398-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048857A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200200900Medicaid
IN200200900Medicaid
742420KMedicare ID - Type Unspecified