Provider Demographics
NPI:1275657231
Name:WRIGHT, BRENT DOUGLAS (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DOUGLAS
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 1:205 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5540
Mailing Address - Country:US
Mailing Address - Phone:707-964-1251
Mailing Address - Fax:707-961-2722
Practice Address - Street 1:205 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5540
Practice Address - Country:US
Practice Address - Phone:707-964-1251
Practice Address - Fax:707-961-2722
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67482207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03967FMedicaid
CAEH816AOtherPTAN
CAG90641Medicare UPIN
CA551813Medicare ID - Type Unspecified