Provider Demographics
NPI:1962605857
Name:JOHNSON, DEREK BRENT (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:BRENT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 LOWER SADDLEBACK RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-4829
Mailing Address - Country:US
Mailing Address - Phone:801-707-7423
Mailing Address - Fax:
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157-2520
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT359058-1204207L00000X
MO2006018684390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program