Provider Demographics
NPI:1508825365
Name:VILLATA, RICHARD B (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:VILLATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:KOTT
Other - Last Name:VILLATA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:519 S ELIZABETH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-3810
Mailing Address - Country:US
Mailing Address - Phone:801-419-3893
Mailing Address - Fax:
Practice Address - Street 1:519 S ELIZABETH ST STE 1
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3810
Practice Address - Country:US
Practice Address - Phone:801-419-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT353333-12052083X0100X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace MedicineGroup - Multi-Specialty