Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 01038107A | IN |
Y | 111NI0900X | Internist | 01038107A | IN |
NPI | 1003286758 |
---|---|
Provider Name | Dr. Willard Dere |
First Address | Salt Lake City, UT 84112-5339 |
Second Address | Salt Lake City, UT 84148-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/10/2015 |
Last Update Date | 06/10/2015 |