Provider Demographics
NPI:1689684185
Name:WILLESEN, KAVITA G (MD)
Entity Type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:G
Last Name:WILLESEN
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 1:8165 S WILLOW CREEK CV
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6203
Mailing Address - Country:US
Mailing Address - Phone:385-308-8937
Mailing Address - Fax:
Practice Address - Street 1:6965 S UNION PARK CTR STE 430
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-6507
Practice Address - Country:US
Practice Address - Phone:385-308-8937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50493791205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057041Medicaid
UT942854057041Medicaid
UT005531005Medicare PIN
UTG90903Medicare UPIN