Provider Demographics
NPI:1952329930
Name:WRIGHT, JACK M (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:M
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 1:4001 LONG PRAIRIE RD STE 125
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1532
Mailing Address - Country:US
Mailing Address - Phone:972-539-3030
Mailing Address - Fax:972-539-3037
Practice Address - Street 1:4001 LONG PRAIRIE RD STE 125
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1532
Practice Address - Country:US
Practice Address - Phone:972-539-3030
Practice Address - Fax:972-539-3037
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7733207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115796806Medicaid
TX115796804Medicaid
TX115796805Medicaid
TX8D2572Medicare ID - Type Unspecified
TX115796804Medicaid
TX8D0818Medicare ID - Type Unspecified
TX8L8968Medicare PIN