Provider Demographics
NPI:1720169915
Name:WILLICK, STUART ELIOT (MD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:ELIOT
Last Name:WILLICK
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:PO BOX 58108
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0108
Mailing Address - Country:US
Mailing Address - Phone:801-581-3998
Mailing Address - Fax:
Practice Address - Street 1:1493 LOWELL AVE
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060
Practice Address - Country:US
Practice Address - Phone:435-655-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371707-1205207QS0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine