Provider Demographics
NPI:1851779938
Name:JOHNSON, CLINTON (DO)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
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 1:8372 S BELLINGHAM DR APT A213
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2185
Mailing Address - Country:US
Mailing Address - Phone:801-309-0603
Mailing Address - Fax:
Practice Address - Street 1:350 S 400 E
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4932
Practice Address - Country:US
Practice Address - Phone:385-399-7800
Practice Address - Fax:385-399-7799
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11297720-1204208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program