Healthcare Provider Details

I. General information

NPI: 1164700738
Provider Name (Legal Business Name): KEVIN WRIGHT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E. 4TH STREET
PHOENIX OR
97535
US

IV. Provider business mailing address

105 E. 4TH STREET
PHOENIX OR
97535
US

V. Phone/Fax

Practice location:
  • Phone: 707-570-9111
  • Fax:
Mailing address:
  • Phone: 707-570-9111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD192149
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD192149
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: