Provider Demographics
NPI:1477694198
Name:THEODORE S. WRIGHT, MD
Entity Type:Organization
Organization Name:THEODORE S. WRIGHT, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:773-777-2620
Mailing Address - Street 1:3607 OLD CONEJO RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2123
Mailing Address - Country:US
Mailing Address - Phone:805-375-0800
Mailing Address - Fax:
Practice Address - Street 1:4757 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-1504
Practice Address - Country:US
Practice Address - Phone:773-777-2620
Practice Address - Fax:773-777-3030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065761207Q00000X
IL0350657612083X0100X
ILAW2016651332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601076OtherBCBS
IL728700Medicare PIN
IL31601076OtherBCBS