Provider Demographics
NPI:1750363123
Name:BIGELOW, JENNIFER IRENE WAKELAND (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:IRENE WAKELAND
Last Name:BIGELOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:I
Other - Last Name:WAKELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:461 TOWN CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158
Mailing Address - Country:US
Mailing Address - Phone:317-567-7954
Mailing Address - Fax:317-834-9399
Practice Address - Street 1:461 TOWN CENTER ROAD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158
Practice Address - Country:US
Practice Address - Phone:317-567-7954
Practice Address - Fax:317-834-9399
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050867A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200198850Medicaid
226870BMedicare ID - Type Unspecified
IN200198850Medicaid
INH00869Medicare UPIN