Healthcare Provider Details

I. General information

NPI: 1801103072
Provider Name (Legal Business Name): JOHN R BACON, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
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:
Mailing address:
  • Phone: 410-321-0284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN RICHARD BACON
Title or Position: ALLERGIST
Credential: MD
Phone: 410-321-0284