Provider Demographics
NPI:1194340745
Name:JOHNSON, GAVIN LANE (OD)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:LANE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E 750 N
Mailing Address - Street 2:
Mailing Address - City:MANTUA
Mailing Address - State:UT
Mailing Address - Zip Code:84324-4343
Mailing Address - Country:US
Mailing Address - Phone:435-730-3998
Mailing Address - Fax:
Practice Address - Street 1:34 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-2527
Practice Address - Country:US
Practice Address - Phone:435-723-2485
Practice Address - Fax:435-723-5840
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12753476-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist