Provider Demographics
NPI:1679582282
Name:JOHNSEN, JUSTIN RODNEY (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RODNEY
Last Name:JOHNSEN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 E 3300 S STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2737
Mailing Address - Country:US
Mailing Address - Phone:801-807-8811
Mailing Address - Fax:801-769-0904
Practice Address - Street 1:2505 E 3300 S STE 202
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-2737
Practice Address - Country:US
Practice Address - Phone:801-807-8811
Practice Address - Fax:801-769-0904
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6139294-1205207WX0200X
IDM-14780207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTI00641Medicare UPIN
UT20340456Medicare PIN