Basic Information
| Provider Information | |||||||||
| NPI: | 1740661792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARK R JOHNSON MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 307 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012946907 | ||||||||
| FaxNumber: | 8012946917 | ||||||||
| Practice Location | |||||||||
| Address1: | 1899 E SIESTA DR | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD HEIGHTS | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840936241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8501631821 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2015 | ||||||||
| LastUpdateDate: | 06/16/2015 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8016318210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KADENCE TECHNOLOGY, INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 184901-1205 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.