Provider Demographics
NPI:1922367309
Name:WOLENSKI, MATTHEW WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WALTER
Last Name:WOLENSKI
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 1:250 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:SUITE 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:2012-05-07
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01077204A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201093880Medicaid
IN201093880Medicaid