Provider Demographics
NPI:1841322831
Name:WRIGHT, MARK THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5200 N ILLINOIS ST
Mailing Address - Street 2:STE 105
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3454
Mailing Address - Country:US
Mailing Address - Phone:618-222-8888
Mailing Address - Fax:618-222-8802
Practice Address - Street 1:5200 N ILLINOIS ST
Practice Address - Street 2:STE 105
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3454
Practice Address - Country:US
Practice Address - Phone:618-222-8888
Practice Address - Fax:618-222-8802
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U88003Medicare UPIN