Provider Demographics
NPI:1083654065
Name:JOHNSON, WENDELL C (MD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5444 S. GREEN ST.
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-262-8120
Mailing Address - Fax:801-262-5721
Practice Address - Street 1:5444 S. GREEN ST.
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5632
Practice Address - Country:US
Practice Address - Phone:801-262-2647
Practice Address - Fax:801-262-3897
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-102932085R0202X
UT276179-12052085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD3403Medicaid
UTH14156Medicare UPIN
UT005542736Medicare PIN