Provider Demographics
NPI:1013583608
Name:WILSON, CALLY (MD)
Entity type:Individual
Prefix:
First Name:CALLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CALLY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1185 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-5282
Mailing Address - Country:US
Mailing Address - Phone:812-847-2281
Mailing Address - Fax:
Practice Address - Street 1:1210 N 1000 W
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-5013
Practice Address - Country:US
Practice Address - Phone:812-847-4481
Practice Address - Fax:844-658-7526
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01088995A207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine