Provider Demographics
NPI:1770675282
Name:WRIGHT, FORREST HOLT (MD)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:HOLT
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 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-635-5019
Mailing Address - Fax:318-226-1759
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 5A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-635-5019
Practice Address - Fax:318-226-1759
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016390208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1354562Medicaid
LA5J592Medicare ID - Type Unspecified
LA1354562Medicaid