Provider Demographics
NPI:1508079310
Name:TWIN PEAKS MEDICAL P.C.
Entity Type:Organization
Organization Name:TWIN PEAKS MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-879-4982
Mailing Address - Street 1:PO BOX 71043
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0043
Mailing Address - Country:US
Mailing Address - Phone:801-879-4982
Mailing Address - Fax:801-446-1474
Practice Address - Street 1:5117 W 8180 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-5922
Practice Address - Country:US
Practice Address - Phone:801-879-4982
Practice Address - Fax:801-446-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT268117-0501213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055781Medicare UPIN
UT6184690001Medicare NSC