Individual
THEODORE ERNEST WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1002 WISHARD BLVD, INDIANAPOLIS, IN 46202-4163
(317) 944-3966
(317) 968-1354
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207SG0201X
Clinical Genetics (M.D.) Physician
Primary
01079354A
IN
208000000X
Pediatrics Physician
01079354A
IN
208000000X
Pediatrics Physician
P27658
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001126408
ANTHEM PTAN
IN
01
—
1102391322
ANTHEM PTAN
IN
05
—
300007251
—
IN
Enumeration date
05/18/2012
Last updated
02/21/2025
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