Healthcare Provider Details

I. General information

NPI: 1184668659
Provider Name (Legal Business Name): MARK DALE JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 S REDWOOD RD SUITE 201
SALT LAKE CITY UT
84123-6798
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-2212
  • Fax: 801-265-0103
Mailing address:
  • Phone: 801-265-2212
  • Fax: 801-265-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number182573-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: