Healthcare Provider Details

I. General information

NPI: 1063732428
Provider Name (Legal Business Name): LOUISE N BACON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26732 CROWN VALLEY PKWY SUITE 351
MISSION VIEJO CA
92691-6306
US

IV. Provider business mailing address

26732 CROWN VALLEY PKWY SUITE 351
MISSION VIEJO CA
92691-6306
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-1007
  • Fax: 949-364-0317
Mailing address:
  • Phone: 949-364-1007
  • Fax: 949-364-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number135799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: