Provider Demographics
NPI:1487636569
Name:WIGBOLDY, JAY FOSTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:FOSTER
Last Name:WIGBOLDY
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 1:5901 TECHNOLOGY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6013
Mailing Address - Country:US
Mailing Address - Phone:317-972-9669
Mailing Address - Fax:317-715-9990
Practice Address - Street 1:5901 TECHNOLOGY CENTER DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-6013
Practice Address - Country:US
Practice Address - Phone:317-972-9669
Practice Address - Fax:317-715-9990
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01079663A2085R0202X
KY344892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055776Medicaid
NYVADOOOMedicare UPIN