Basic Information
| Provider Information | |||||||||
| NPI: | 1366408650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10002 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853180002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235617222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18701 N 67TH AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235617222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 12/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 17772 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3981220 | 01 | AZ | EVERCARE GRP | OTHER | AZ0728670 | 01 | AZ | BLUE CROSS BLUE SHIELD GR | OTHER | 097990 | 05 | AZ | MEDICAID | AW1436 | 01 | AZ | HEALTHNET GRP | OTHER |