Provider Demographics
NPI:1487747408
Name:JOHNSON, SPENCER (OD)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
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 1:12357 S 450 E STE 2
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8127
Mailing Address - Country:US
Mailing Address - Phone:801-572-9804
Mailing Address - Fax:801-572-9805
Practice Address - Street 1:12357 S 450 E STE 2
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8127
Practice Address - Country:US
Practice Address - Phone:801-572-9804
Practice Address - Fax:801-572-9805
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5937796-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV06462Medicare UPIN