Basic Information
| Provider Information | |||||||||
| NPI: | 1396755187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 WARRENSVILLE CENTER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SHAKER HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162866295 | ||||||||
| FaxNumber: | 2162866341 | ||||||||
| Practice Location | |||||||||
| Address1: | 11100 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2168443800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-060828 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 364150 | 01 | OH | WELLCARE | OTHER | 0643909 | 01 | OH | AETNA | OTHER | 000000224345 | 01 | OH | UNISON | OTHER | 0832460 | 05 | OH | MEDICAID | 746010 | 01 | OH | BUCKEYE | OTHER | 000000539619 | 01 | OH | ANTHEM | OTHER |