Provider Demographics
NPI:1568410579
Name:WRIGHT, KENNETH J (MD,)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 W WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1852
Mailing Address - Country:US
Mailing Address - Phone:813-348-9088
Mailing Address - Fax:813-348-9310
Practice Address - Street 1:2809 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1852
Practice Address - Country:US
Practice Address - Phone:813-348-9088
Practice Address - Fax:813-348-9310
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL295172086S0129X
FLME1051642086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME15684OtherLICENSE
FL002462600Medicaid
FLME15684OtherLICENSE