Healthcare Provider Details

I. General information

NPI: 1083654065
Provider Name (Legal Business Name): WENDELL C JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5444 S. GREEN ST.
MURRAY UT
84123-5632
US

IV. Provider business mailing address

5444 S. GREEN ST.
MURRAY UT
84123-5632
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-2647
  • Fax: 801-262-3897
Mailing address:
  • Phone: 801-262-8120
  • Fax: 801-262-5721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberM-10293
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number276179-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number276179-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: