Healthcare Provider Details

I. General information

NPI: 1255391132
Provider Name (Legal Business Name): JEFFREY LANCE BACON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 FAIRHURST ST
STERLING CO
80751-4564
US

IV. Provider business mailing address

1010 N COUNTRY CLUB DR
MESA AZ
85201-3309
US

V. Phone/Fax

Practice location:
  • Phone: 970-521-3223
  • Fax:
Mailing address:
  • Phone: 480-461-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38444
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: