Provider Demographics
NPI:1417374323
Name:WILLER, ROBERT J JR (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:WILLER
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-464-7788
Mailing Address - Fax:
Practice Address - Street 1:2000 S 900 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3208
Practice Address - Country:US
Practice Address - Phone:801-464-7788
Practice Address - Fax:801-464-7787
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10237462-1204208M00000X, 208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program