Provider Demographics
NPI:1538926811
Name:WILDMAN, MICHAEL WALTER (ND)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WALTER
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:MICHAEL
Other - Last Name:WILDMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ND
Mailing Address - Street 1:1138 CHATTANOOGA CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-9611
Mailing Address - Country:US
Mailing Address - Phone:812-298-4841
Mailing Address - Fax:
Practice Address - Street 1:5602 CAITO DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1346
Practice Address - Country:US
Practice Address - Phone:317-942-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2025-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101YA0400X
390200000X
INND20250213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program