Provider Demographics
NPI: | 1114115763 |
---|---|
Name: | COREY B JOHNSON MD PC |
Entity Type: | Organization |
Organization Name: | COREY B JOHNSON MD PC |
Other - Org Name: | CACHE VEIN CARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | COREY |
Authorized Official - Middle Name: | B |
Authorized Official - Last Name: | JOHNSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 435-753-2842 |
Mailing Address - Street 1: | 1219 N 400 E |
Mailing Address - Street 2: | |
Mailing Address - City: | LOGAN |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84341-2321 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 435-753-2842 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1219 N 400 E |
Practice Address - Street 2: | |
Practice Address - City: | LOGAN |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84341-2321 |
Practice Address - Country: | US |
Practice Address - Phone: | 435-753-2842 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-10-09 |
Last Update Date: | 2007-10-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 1848241205 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Single Specialty |