Provider Demographics
NPI:1184668659
Name:JOHNSON, MARK DALE (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DALE
Last Name:JOHNSON
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:801-265-2212
Mailing Address - Fax:801-265-0103
Practice Address - Street 1:6321 S REDWOOD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-6798
Practice Address - Country:US
Practice Address - Phone:801-265-2212
Practice Address - Fax:801-265-0103
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT182573-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529190498001Medicaid
000059117Medicare PIN
E93293Medicare UPIN