Healthcare Provider Details

I. General information

NPI: 1902967508
Provider Name (Legal Business Name): ALFRED E BACON III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 01/09/2019
Certification Date:
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 NumberC10002927
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: