Provider Demographics
NPI:1275790776
Name:JOHNSON, DALE GEDGE (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:GEDGE
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 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1100
Mailing Address - Country:US
Mailing Address - Phone:801-662-2950
Mailing Address - Fax:801-662-2980
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:SUITE 2600
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1100
Practice Address - Country:US
Practice Address - Phone:801-662-2950
Practice Address - Fax:801-662-2980
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14737812052086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT03594Medicaid
UTD20352Medicare UPIN