Provider Demographics
NPI:1689991358
Name:JOHNSON, BENJAMIN FREDRICK (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:FREDRICK
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 1:2807 E 4215 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2900
Mailing Address - Country:US
Mailing Address - Phone:385-315-0214
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7771155-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10000009766001OtherREGENCE BLUE CROSS BLUE SHIELD
UTU000078668OtherMEDICARE PTAN
UT1689991358Medicaid