Provider Demographics
NPI:1265876171
Name:JOHNSON, BRETT ALAN (DO)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:ALAN
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:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:735-283-4076
Mailing Address - Fax:
Practice Address - Street 1:525 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-1155
Practice Address - Country:US
Practice Address - Phone:435-283-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105310737-1204207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine