Provider Demographics
NPI:1649214537
Name:WRIGHT, KEITH D (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:D
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 1:2383 PATE ST
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-972-4845
Mailing Address - Fax:770-972-0358
Practice Address - Street 1:2383 PATE ST
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-972-4845
Practice Address - Fax:770-972-0358
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043822207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G68489Medicare UPIN
GA07BB5DBMedicare ID - Type Unspecified