Provider Demographics
NPI:1730190992
Name:WILSON, DONALD LEON (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEON
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 4507
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46082
Mailing Address - Country:US
Mailing Address - Phone:317-817-1359
Mailing Address - Fax:317-805-2159
Practice Address - Street 1:201 PENNSYLVANIA PKWY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280
Practice Address - Country:US
Practice Address - Phone:317-817-1359
Practice Address - Fax:317-805-2159
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021266A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B95739Medicare UPIN
IN3316470Medicare ID - Type Unspecified