Provider Demographics
NPI:1902914427
Name:JOHNSON, GEORGE BRENT (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:BRENT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 N 1100 E
Mailing Address - Street 2:SUITE A
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2054
Mailing Address - Country:US
Mailing Address - Phone:801-855-3843
Mailing Address - Fax:801-855-3854
Practice Address - Street 1:226 N 1100 E
Practice Address - Street 2:SUITE A
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2054
Practice Address - Country:US
Practice Address - Phone:801-855-3843
Practice Address - Fax:801-855-3854
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1583051205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05172Medicaid
UT05172Medicaid