Provider Demographics
NPI:1336443373
Name:GLEN E JOHNSON MD PC
Entity Type:Organization
Organization Name:GLEN E JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-966-3700
Mailing Address - Street 1:555 E 4500 S STE C150
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4507
Mailing Address - Country:US
Mailing Address - Phone:801-288-0747
Mailing Address - Fax:801-288-0761
Practice Address - Street 1:3940 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5450
Practice Address - Country:US
Practice Address - Phone:801-966-3700
Practice Address - Fax:801-966-9421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT154764-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty