Healthcare Provider Details

I. General information

NPI: 1205904679
Provider Name (Legal Business Name): INFECTIOUS DISEASE ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 OMEGA DR BLDG C
NEWARK DE
19713-2064
US

IV. Provider business mailing address

78 OMEGA DR BLDG C
NEWARK DE
19713-2064
US

V. Phone/Fax

Practice location:
  • Phone: 302-368-2883
  • Fax: 302-368-2892
Mailing address:
  • Phone: 302-368-2883
  • Fax: 302-368-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ALFRED BACON
Title or Position: PRACTICE OWNER
Credential: M.D.
Phone: 302-368-2883