Provider Demographics
NPI:1740661792
Name:MARK R JOHNSON MD PC
Entity type:Organization
Organization Name:MARK R JOHNSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-631-8210
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:801-294-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:1899 E SIESTA DR
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84093-6241
Practice Address - Country:US
Practice Address - Phone:850-163-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KADENCE TECHNOLOGY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184901-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty