Provider Demographics
NPI:1376510800
Name:JOHNSON, SHERMAN BENNION (MD)
Entity Type:Individual
Prefix:
First Name:SHERMAN
Middle Name:BENNION
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 1:2520 W 4700 S
Mailing Address - Street 2:#5A
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-1847
Mailing Address - Country:US
Mailing Address - Phone:801-964-2008
Mailing Address - Fax:801-964-2435
Practice Address - Street 1:2520 W 4700 S
Practice Address - Street 2:#5A
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-1847
Practice Address - Country:US
Practice Address - Phone:801-964-2008
Practice Address - Fax:801-964-2435
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1646671205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI10060Medicare UPIN
UT005752803Medicare ID - Type Unspecified