Provider Demographics
NPI:1205813052
Name:BACON, KENNETH TERRY (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:TERRY
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 1:12221 MOPAC EXPRESSWAY NORTH
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2483
Mailing Address - Country:US
Mailing Address - Phone:512-901-8748
Mailing Address - Fax:512-901-8755
Practice Address - Street 1:8038 MESA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1319
Practice Address - Country:US
Practice Address - Phone:512-901-8748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD59022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82R046Medicare PIN
TXP00433569Medicare PIN
TXD47879Medicare UPIN