Provider Demographics
NPI:1225053903
Name:BACON, MERRILL PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:MERRILL
Middle Name:PHILIP
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 1:11999 SAN VICENTE BLVD
Mailing Address - Street 2:STE. 440
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5131
Mailing Address - Country:US
Mailing Address - Phone:310-440-3131
Mailing Address - Fax:
Practice Address - Street 1:3400 LOMA VISTA RD
Practice Address - Street 2:STE. 9
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3033
Practice Address - Country:US
Practice Address - Phone:805-644-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC31585207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C315850Medicaid
CAWC31585DMedicare PIN
CA00C315850Medicaid