Provider Demographics
NPI:1780669267
Name:WILSON, DERRON (MD)
Entity Type:Individual
Prefix:
First Name:DERRON
Middle Name:
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 1:13345 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3318
Mailing Address - Country:US
Mailing Address - Phone:317-396-1300
Mailing Address - Fax:317-870-2728
Practice Address - Street 1:13345 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3318
Practice Address - Country:US
Practice Address - Phone:317-396-1300
Practice Address - Fax:317-870-2728
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047150A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200313770BMedicaid
IN4723080004Medicare NSC
IN200313770BMedicaid
IN061570AAAMedicare ID - Type Unspecified