MEDICARE: DR. GEOFFREY BACON M.D.

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
1	207Y00000X	Otolaryngology Physician	0101048019	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	235056	OTHER	VA	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407856610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEOFFREY BACON M.D.

Provider Business Mailing Address
First Line	:	901 ENTERPRISE PKWY
Second Line	:	SUITE 300
City	:	HAMPTON
State	:	VA
Zip	:	23666-6249
Country	:	US
Telephone Number	:	757-825-2500
Fax Number	:	757-825-2521

Provider Business Practice Location Address
First Line	:	901 ENTERPRISE PARKWAY
Second Line	:	SUITE 300
City	:	HAMPTON
State	:	VA
Zip	:	23666-2583
Country	:	US
Telephone Number	:	757-825-2500
Fax Number	:	757-825-2521

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2005
Last Update Date	:	04/09/2020

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