Provider Demographics
NPI:1326157298
Name:JOHNSON, GLEN ERIC (MD)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ERIC
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 1:555 E 4500 S
Mailing Address - Street 2:C-150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4533
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:801-288-0761
Practice Address - Street 1:3940 WEST 4100 SOUTH
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-966-3700
Practice Address - Fax:801-966-9421
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT15476412052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D20411Medicare UPIN
UT000004641Medicare ID - Type Unspecified
UTU000004641Medicare PIN