Healthcare Provider Details

I. General information

NPI: 1659341063
Provider Name (Legal Business Name): FATIMA VILICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12202 DEER MOUNTAIN BLVD # 101-1740
KAMAS UT
84036-9353
US

IV. Provider business mailing address

12202 DEER MOUNTAIN BLVD # 101-1740
KAMAS UT
84036-9353
US

V. Phone/Fax

Practice location:
  • Phone: 435-782-9384
  • Fax: 847-919-8661
Mailing address:
  • Phone: 435-782-9384
  • Fax: 847-919-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number36097212
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10369211205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: