Provider Demographics
NPI:1396839403
Name:JOHNSON, MICHAEL RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2090 GENOVA DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6107
Mailing Address - Country:US
Mailing Address - Phone:801-495-0735
Mailing Address - Fax:
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY
Practice Address - Street 2:STE 201
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4652
Practice Address - Country:US
Practice Address - Phone:801-254-9700
Practice Address - Fax:801-254-9755
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT4550767-12052080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine