Provider Demographics
NPI:1861428856
Name:WILCOX, TODD R (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:R
Last Name:WILCOX
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 1:2263 COTTONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7601
Mailing Address - Country:US
Mailing Address - Phone:801-424-1500
Mailing Address - Fax:801-272-2859
Practice Address - Street 1:3415 S 900 W
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84119-4103
Practice Address - Country:US
Practice Address - Phone:801-918-3692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT264359-1205207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870639098001Medicaid
G36276Medicare UPIN
UT870639098001Medicaid