Provider Demographics
NPI:1164450797
Name:BACON, DAVID S (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:S
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15609
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704
Mailing Address - Country:US
Mailing Address - Phone:919-384-0200
Mailing Address - Fax:919-384-0600
Practice Address - Street 1:3643 N ROXBORO RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704
Practice Address - Country:US
Practice Address - Phone:919-470-6186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34510207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7912491Medicaid
NC2202291Medicare ID - Type Unspecified
NC7912491Medicaid