Provider Demographics
NPI:1629064027
Name:WING, ROBERT WILLLIAM (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILLLIAM
Last Name:WING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1866
Mailing Address - Country:US
Mailing Address - Phone:801-476-0494
Mailing Address - Fax:801-476-0067
Practice Address - Street 1:4360 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1866
Practice Address - Country:US
Practice Address - Phone:801-476-0494
Practice Address - Fax:801-476-0067
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT166287 1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT59266629001/1945OtherBLUE CROSS ID NUMBER
UTD07575Medicare UPIN
UT000002797Medicare ID - Type Unspecified