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General NPI Number Information
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NPI Number | 1114115763
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Entity Type | Organization
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Legal Business Name | COREY B JOHNSON MD PC
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Dates
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Enumeration Date | 10/09/2007
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 1219 N 400 E
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City | LOGAN
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State | UT
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Zip | 84341-2321
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Country | US
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Telephone | 435-753-2842
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Fax |
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Provider Business Mailing Address
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Address Line | 1219 N 400 E
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City | LOGAN
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State | UT
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Zip | 84341-2321
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Country | US
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Telephone | 435-753-2842
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. COREY B JOHNSON
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Credential | MD
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Telephone | 435-753-2842
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 1848241205
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License Number State | UT
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