Provider Demographics
NPI:1124171251
Name:JOHN WALLACE WRIGHT,DPM,PC
Entity type:Organization
Organization Name:JOHN WALLACE WRIGHT,DPM,PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:478-452-7342
Mailing Address - Street 1:151 N JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-3415
Mailing Address - Country:US
Mailing Address - Phone:478-452-7342
Mailing Address - Fax:478-452-7342
Practice Address - Street 1:151 N JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3415
Practice Address - Country:US
Practice Address - Phone:478-452-7342
Practice Address - Fax:478-452-7342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA575213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1508861493OtherINDIVIDUAL NPI
GAGRP4962Medicare ID - Type UnspecifiedGROUP NUMBER