Provider Demographics
NPI:1659375335
Name:WILSON, JANE ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:ELLEN
Last Name:WILSON
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 1:250 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:
Mailing Address - Fax:
Practice Address - Street 1:5550 S EAST ST
Practice Address - Street 2:STE.I
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1979
Practice Address - Country:US
Practice Address - Phone:317-780-4080
Practice Address - Fax:317-780-4088
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010471512080A0000X
IN01047151A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000507395OtherANTHEM
IN200181770Medicaid
INI72427Medicare UPIN
IN200181770Medicaid
IN715530ARRRMedicare PIN