Provider Demographics
NPI:1710071493
Name:JOHNSSON, STAFFAN C (MD)
Entity Type:Individual
Prefix:
First Name:STAFFAN
Middle Name:C
Last Name:JOHNSSON
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 1:2975 W EXECUTIVE PKWY
Mailing Address - Street 2:200
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:1034 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-993-9582
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78-163256-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT36023OtherDESERET MUTUAL
UT107006658101OtherIHC
UT1502954OtherUMWA
UT870545614JO1OtherEDUCATORS MUTUAL
UTQM0000075886OtherALTIUS
UT37797OtherPEHP
UTPRA04852OtherMOLINA
UT2090168OtherUNITED HEALTHCARE
UT53247OtherHEALTHY U
AZ708753Medicaid
AZ708753Medicaid