Provider Demographics
NPI:1275797417
Name:JOHNSON, LAGRAND (DO)
Entity Type:Individual
Prefix:
First Name:LAGRAND
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 NORTH 550 WEST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062
Mailing Address - Country:US
Mailing Address - Phone:801-592-8149
Mailing Address - Fax:
Practice Address - Street 1:326 HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5620
Practice Address - Country:US
Practice Address - Phone:801-423-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT323252-1204208D00000X
CA20A 6898208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice