Healthcare Provider Details

I. General information

NPI: 1487706099
Provider Name (Legal Business Name): CLARK WOODROW JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 12/08/2024
Certification Date: 12/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E 3300 S
SALT LAKE CITY UT
84106-2522
US

IV. Provider business mailing address

1208 E 3300 S
SALT LAKE CITY UT
84106-2522
US

V. Phone/Fax

Practice location:
  • Phone: 801-290-5320
  • Fax: 801-290-5321
Mailing address:
  • Phone: 801-290-5320
  • Fax: 801-290-5321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number241524
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number7821510-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 60082250
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD 29092
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: