Healthcare Provider Details

I. General information

NPI: 1508825365
Provider Name (Legal Business Name): RICHARD B VILLATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RICHARD KOTT VILLATA MD

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 S ELIZABETH ST STE 1
SALT LAKE CITY UT
84102-3810
US

IV. Provider business mailing address

519 S ELIZABETH ST STE 1
SALT LAKE CITY UT
84102-3810
US

V. Phone/Fax

Practice location:
  • Phone: 801-419-3893
  • Fax:
Mailing address:
  • Phone: 801-419-3893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number353333-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number353333-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: