MEDICARE: BLAKE WILSON JOHNSON D.O.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	012210	AZ
2	207L00000X	Anesthesiology Physician	6919190-1240	UT
3	207L00000X	Anesthesiology Physician	94-06211 TEMPORARY	KS

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1760502991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE WILSON JOHNSON D.O.

Provider Business Mailing Address
First Line	:	PO BOX 1847
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85299-1847
Country	:	US
Telephone Number	:	480-507-2961
Fax Number	:	480-507-2971

Provider Business Practice Location Address
First Line	:	3580 W 9000 S
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-8812
Country	:	US
Telephone Number	:	801-561-8888
Fax Number	:	480-507-2971

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	06/11/2026

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308