Healthcare Provider Details

I. General information

NPI: 1790894673
Provider Name (Legal Business Name): WILLIAM KEVIN WRIGHT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 HOMER M ADAMS PKWY
ALTON IL
62002-4856
US

IV. Provider business mailing address

2865 HOMER M ADAMS PKWY
ALTON IL
62002-4856
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-1654
  • Fax: 618-465-8652
Mailing address:
  • Phone: 618-465-1654
  • Fax: 618-465-8652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT02601
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: