Healthcare Provider Details

I. General information

NPI: 1215934476
Provider Name (Legal Business Name): DONNA LOUISE BACON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2005
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1282 US HIGHWAY 1 STE 1
ROCKLEDGE FL
32955-2747
US

IV. Provider business mailing address

1282 US HIGHWAY 1 STE 1
ROCKLEDGE FL
32955-2747
US

V. Phone/Fax

Practice location:
  • Phone: 321-631-3693
  • Fax: 321-631-7618
Mailing address:
  • Phone: 321-631-3693
  • Fax: 844-772-0718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME71719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: