Provider Demographics
NPI:1639180698
Name:JOHNSON, COREY B (MD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:B
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 1:139 S 200 W
Mailing Address - Street 2:
Mailing Address - City:HYRUM
Mailing Address - State:UT
Mailing Address - Zip Code:84319-1241
Mailing Address - Country:US
Mailing Address - Phone:435-245-3348
Mailing Address - Fax:
Practice Address - Street 1:1219 N 400 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2321
Practice Address - Country:US
Practice Address - Phone:435-753-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1848241205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E14837Medicare UPIN