Provider Demographics
NPI:1699768838
Name:UTLEY, WILLIAM RICHARD (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:UTLEY
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 1:855 A AVE NE
Mailing Address - Street 2:STE 300
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5057
Mailing Address - Country:US
Mailing Address - Phone:319-368-9300
Mailing Address - Fax:319-368-5690
Practice Address - Street 1:855 A AVE NE
Practice Address - Street 2:STE 300
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5057
Practice Address - Country:US
Practice Address - Phone:319-368-9300
Practice Address - Fax:319-368-5690
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036108990208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036108990Medicaid
IL036108990Medicaid