Healthcare Provider Details

I. General information

NPI: 1720169915
Provider Name (Legal Business Name): STUART ELIOT WILLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 LOWELL AVE
PARK CITY UT
84060
US

IV. Provider business mailing address

PO BOX 58108
SALT LAKE CITY UT
84158-0108
US

V. Phone/Fax

Practice location:
  • Phone: 435-655-7970
  • Fax:
Mailing address:
  • Phone: 801-581-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number371707-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number371707-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: