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NPI Code Detail

MEDICARE: JEFFREY LANCE BACON D.O.

MEDICARE: JEFFREY LANCE BACON D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician38444CO

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1255391132
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEFFREY LANCE BACON D.O.
Provider Business Mailing Address
First Line : 1010 N COUNTRY CLUB DR
Second Line :
City : MESA
State : AZ
Zip : 85201-3309
Country : US
Telephone Number : 480-461-2409
Fax Number :
Provider Business Practice Location Address
First Line : 615 FAIRHURST ST
Second Line :
City : STERLING
State : CO
Zip : 80751-4564
Country : US
Telephone Number : 970-521-3223
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 03/18/2008

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