Provider Demographics
NPI:1417931643
Name:WRIGHT, MALCOLM G (M D)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:G
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 STARLING STREET
Mailing Address - Street 2:SUITE 402
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4219
Mailing Address - Country:US
Mailing Address - Phone:912-554-0111
Mailing Address - Fax:912-554-0830
Practice Address - Street 1:2500 STARLING STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4219
Practice Address - Country:US
Practice Address - Phone:912-554-0111
Practice Address - Fax:912-554-0830
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA023510OtherBLUE SHIELD
GAGRP2603OtherGROUP MEDICARE #
GA581596796OtherTRICARE
GA000286954AMedicaid
GA080064654OtherRAILROAD MEDICARE
GA000286954AMedicaid