Provider Demographics
NPI:1346494754
Name:BACON, MATTHEW KEITH (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KEITH
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 1:800 ROSE ST
Mailing Address - Street 2:MN470
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0001
Mailing Address - Country:US
Mailing Address - Phone:859-338-4096
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:MN470
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0001
Practice Address - Country:US
Practice Address - Phone:859-338-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY449662080P0203X
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine