Provider Demographics
NPI:1699035030
Name:WILSON, THEODORE ERNEST (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:ERNEST
Last Name:WILSON
Suffix:
Gender:
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 1:1002 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4163
Practice Address - Country:US
Practice Address - Phone:317-944-3966
Practice Address - Fax:317-968-1354
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-18
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP27658208000000X
IN01079354A208000000X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001126408OtherANTHEM PTAN
IN1102391322OtherANTHEM PTAN
IN300007251Medicaid