Provider Demographics
NPI:1508861493
Name:WRIGHT, JOHN WALLACE (DPM,PC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WALLACE
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:DPM,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3415
Mailing Address - Country:US
Mailing Address - Phone:478-452-7342
Mailing Address - Fax:478-452-7342
Practice Address - Street 1:151 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3415
Practice Address - Country:US
Practice Address - Phone:478-452-7342
Practice Address - Fax:478-452-7342
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA575213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA753297511AMedicaid
IL016-004067OtherILLINOIS LICENSE#
MS80095OtherMISSISSIPPI LICENSE#
GA000360478AMedicaid
GA1124171251OtherORGANIZATIONAL NPI
GA575OtherGEORGIA LICENSE#
GA575OtherGEORGIA LICENSE#
MS80095OtherMISSISSIPPI LICENSE#