Healthcare Provider Details

I. General information

NPI: 1053391771
Provider Name (Legal Business Name): MICHAEL B WILCOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4360 WASHINGTON BLVD
OGDEN UT
84403
US

IV. Provider business mailing address

4360 WASHINGTON BLVD
OGDEN UT
84403
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-0494
  • Fax: 801-476-0067
Mailing address:
  • Phone: 801-476-0494
  • Fax: 801-476-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number3637861205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: