Provider Demographics
NPI:1518536580
Name:WILSON, KURTIS WAYNE (DO)
Entity type:Individual
Prefix:
First Name:KURTIS
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 W SONGER LN
Mailing Address - Street 2:
Mailing Address - City:VEEDERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47987-8547
Mailing Address - Country:US
Mailing Address - Phone:765-762-4180
Mailing Address - Fax:
Practice Address - Street 1:440 W SONGER LN
Practice Address - Street 2:
Practice Address - City:VEEDERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47987-8547
Practice Address - Country:US
Practice Address - Phone:765-762-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02008204A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3810-03-0390OtherDRIVER'S LICENSE