Healthcare Provider Details

I. General information

NPI: 1306088802
Provider Name (Legal Business Name): DONNA L BACON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
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: 321-631-7618

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: DR. DONNA L BACON
Title or Position: PRESIDENT
Credential: MD
Phone: 321-631-3693