Healthcare Provider Details

I. General information

NPI: 1689018079
Provider Name (Legal Business Name): DONALD D BACON MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 OAK CENTRE DR STE 140
SAN ANTONIO TX
78258-3916
US

IV. Provider business mailing address

525 OAK CENTRE DR STE 140
SAN ANTONIO TX
78258-3916
US

V. Phone/Fax

Practice location:
  • Phone: 210-546-1410
  • Fax:
Mailing address:
  • Phone: 210-546-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE2452
License Number StateTX

VIII. Authorized Official

Name: DR. DONALD BACON
Title or Position: OWNER
Credential: MD
Phone: 210-546-1410