Provider Demographics
NPI:1659341063
Name:VILICH, FATIMA (MD)
Entity Type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:VILICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12202 DEER MOUNTAIN BLVD # 101-1740
Mailing Address - Street 2:
Mailing Address - City:KAMAS
Mailing Address - State:UT
Mailing Address - Zip Code:84036-9353
Mailing Address - Country:US
Mailing Address - Phone:435-782-9384
Mailing Address - Fax:847-919-8661
Practice Address - Street 1:12202 DEER MOUNTAIN BLVD # 101-1740
Practice Address - Street 2:
Practice Address - City:KAMAS
Practice Address - State:UT
Practice Address - Zip Code:84036-9353
Practice Address - Country:US
Practice Address - Phone:435-782-9384
Practice Address - Fax:847-919-8661
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10369211205207Q00000X
IL36097212207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36097212Medicaid
H17803Medicare UPIN
IL585630Medicare ID - Type Unspecified