Provider Demographics
NPI:1659453694
Name:JOHNSON, VAUGHN THAD (DO)
Entity Type:Individual
Prefix:DR
First Name:VAUGHN
Middle Name:THAD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 N UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6658
Mailing Address - Country:US
Mailing Address - Phone:801-375-7100
Mailing Address - Fax:801-375-7102
Practice Address - Street 1:3650 N UNIVERSITY AVE STE 200
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6658
Practice Address - Country:US
Practice Address - Phone:801-375-7100
Practice Address - Fax:801-375-7102
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9531048-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine