Provider Demographics
NPI:1760502991
Name:JOHNSON, BLAKE WILSON (DO)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:WILSON
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:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-1847
Mailing Address - Country:US
Mailing Address - Phone:480-507-2961
Mailing Address - Fax:480-507-2971
Practice Address - Street 1:3580 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8812
Practice Address - Country:US
Practice Address - Phone:801-561-8888
Practice Address - Fax:480-507-2971
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-06211 TEMPORARY207L00000X
UT6919190-1240207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1841453362Medicaid
UT000064377Medicare PIN