MEDICARE: DR. JACK LESLIE WRIGHT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD453114	PA

General Provider Information

NPI Number	:	1073561643
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK LESLIE WRIGHT MD

Provider Business Mailing Address
First Line	:	685 GOOD DR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17601-2426
Country	:	US
Telephone Number	:	717-735-3131
Fax Number	:	717-391-9582

Provider Business Practice Location Address
First Line	:	685 GOOD DRIVE
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17604-4125
Country	:	US
Telephone Number	:	717-735-3131
Fax Number	:	717-391-9582

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	02/17/2015

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