Basic Information
| Provider Information | |||||||||
| NPI: | 1174807507 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WRIGHT INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2728 DURANT AVE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108419230 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2728 DURANT AVE | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947041725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108419230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2011 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | NEWMAN | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL TRAINING | ||||||||
| AuthorizedOfficialTelephone: | 5108419230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 17179 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1902089543 | 05 | CA | MEDICAID |