Healthcare Provider Details

I. General information

NPI: 1477694198
Provider Name (Legal Business Name): THEODORE S. WRIGHT, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4757 W MONTROSE AVE
CHICAGO IL
60641-1504
US

IV. Provider business mailing address

3607 OLD CONEJO RD
THOUSAND OAKS CA
91320-2123
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-2620
  • Fax: 773-777-3030
Mailing address:
  • Phone: 805-375-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036065761
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number035065761
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberAW2016651
License Number StateIL

VIII. Authorized Official

Name: DR. THEODORE SIDNEY WRIGHT JR.
Title or Position: PHYSICIAN
Credential:
Phone: 773-777-2620