Provider Demographics
NPI:1508857764
Name:WILSON, WILLIAM E (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:E
Last Name:WILSON
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:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2505
Mailing Address - Country:US
Mailing Address - Phone:812-238-7783
Mailing Address - Fax:812-238-4506
Practice Address - Street 1:315 LANKFORD ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:IN
Practice Address - Zip Code:47841-1008
Practice Address - Country:US
Practice Address - Phone:812-939-2126
Practice Address - Fax:812-939-3414
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00213807OtherRR MEDICARE
IN100369360Medicaid
IN130910MMedicare PIN
INP00213807OtherRR MEDICARE
IN941090X8Medicare PIN
IN252060CMedicare PIN
IN100369360Medicaid