Provider Demographics
NPI:1972545861
Name:JOHNSON, SCOTT EDWARD (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDWARD
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 1:5848 S 300 E
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6121
Mailing Address - Country:US
Mailing Address - Phone:801-314-4900
Mailing Address - Fax:
Practice Address - Street 1:5848 S 300 E
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6121
Practice Address - Country:US
Practice Address - Phone:801-314-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3764581205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057005Medicaid
UTH60252Medicare UPIN
UT942854057005Medicaid