Provider Demographics
NPI:1598830796
Name:WRIGHT, THEODORE SIDNEY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:SIDNEY
Last Name:WRIGHT
Suffix:JR
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 1:4757 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1504
Mailing Address - Country:US
Mailing Address - Phone:773-777-2620
Mailing Address - Fax:773-777-3030
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065761207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31601076OtherBCBS
ILD15508Medicare UPIN
IL728700Medicare PIN