Healthcare Provider Details

I. General information

NPI: 1861428856
Provider Name (Legal Business Name): TODD R WILCOX MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 S 900 W
SOUTH SALT LAKE UT
84119-4103
US

IV. Provider business mailing address

2263 COTTONWOOD CIR
SALT LAKE CITY UT
84117-7601
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-3692
  • Fax:
Mailing address:
  • Phone: 801-424-1500
  • Fax: 801-272-2859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number264359-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number264359-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: