Provider Demographics
NPI:1427126192
Name:JOHNSON, JOSEPH M (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:M
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 1:1675 N 200 W
Mailing Address - Street 2:9C
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-377-4800
Mailing Address - Fax:801-377-4041
Practice Address - Street 1:1675 N 200 W
Practice Address - Street 2:9C
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-377-4800
Practice Address - Fax:801-377-4041
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5868686-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics