MEDICARE: THEODORE S. 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	332900000X	Non-Pharmacy Dispensing Site	AW2016651	IL
2	2083X0100X	Occupational Medicine Physician	035065761	IL
3	207Q00000X	Family Medicine Physician	036065761	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	31601076	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1477694198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THEODORE S. WRIGHT, MD

Provider Business Mailing Address
First Line	:	3607 OLD CONEJO RD
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91320-2123
Country	:	US
Telephone Number	:	805-375-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	4757 W MONTROSE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-1504
Country	:	US
Telephone Number	:	773-777-2620
Fax Number	:	773-777-3030

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. THEODORE SIDNEY WRIGHT JR.
Credential	:
Telephone Number	:	773-777-2620

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	04/27/2009

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