Provider Demographics
NPI:1558877134
Name:JOHNSON, GREGORY WALLACE (RT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WALLACE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 W 1900 S
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-1720
Mailing Address - Country:US
Mailing Address - Phone:801-706-8132
Mailing Address - Fax:
Practice Address - Street 1:769 W 1900 S
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84087-1720
Practice Address - Country:US
Practice Address - Phone:801-706-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT380908-54012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology