Basic Information
| Provider Information | |||||||||
| NPI: | 1962605857 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3136 LOWER SADDLEBACK RD | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840984829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017077423 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5121 S COTTONWOOD STREET | ||||||||
| Address2: | INTERMOUNTAIN MEDICAL CENTER | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841572520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015075248 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 01/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 359058-1204 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | 2006018684 | MO | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.