Healthcare Provider Details

I. General information

NPI: 1538162078
Provider Name (Legal Business Name): JOHN RICHARD BACON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2005
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SISTER PIERRE DR STE 201
TOWSON MD
21204-7525
US

IV. Provider business mailing address

120 SISTER PIERRE DR STE 201
TOWSON MD
21204-7525
US

V. Phone/Fax

Practice location:
  • Phone: 410-321-0284
  • Fax: 410-321-0286
Mailing address:
  • Phone: 410-321-0284
  • Fax: 410-321-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberD0028727
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: