Healthcare Provider Details

I. General information

NPI: 1497863146
Provider Name (Legal Business Name): OLIVER M.L. BACON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARNASSUS AVE # 429
SAN FRANCISCO CA
94143-2202
US

IV. Provider business mailing address

1635 DIVISADERO ST SUITE 625, BOX 1821
SAN FRANCISCO CA
94143-0001
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2119
  • Fax: 415-353-2406
Mailing address:
  • Phone: 415-476-4029
  • Fax: 415-476-4150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA73008
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA73008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: