Basic Information
| Provider Information | |||||||||
| NPI: | 1568769933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WRIGHT DERMATOLOGY AND DIAGNOSTICS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1850 OLD PECOS TRL | ||||||||
| Address2: | STE J | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059885120 | ||||||||
| FaxNumber: | 5059821812 | ||||||||
| Practice Location | |||||||||
| Address1: | 1850 OLD PECOS TRL | ||||||||
| Address2: | STE J | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059885120 | ||||||||
| FaxNumber: | 5059821812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2011 | ||||||||
| LastUpdateDate: | 06/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | VIGIL | ||||||||
| AuthorizedOfficialFirstName: | JENNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING & RECEPTION | ||||||||
| AuthorizedOfficialTelephone: | 5059885120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 2000-129 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 11157598 | 01 | NM | CAQH | OTHER | 2000-129 | 01 | NM | MEDICAL LICENSE | OTHER |