Provider Demographics
NPI:1407856610
Name:BACON, GEOFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:GEOFFREY
Middle Name:
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 1:901 ENTERPRISE PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6249
Mailing Address - Country:US
Mailing Address - Phone:757-825-2500
Mailing Address - Fax:757-825-2521
Practice Address - Street 1:901 ENTERPRISE PARKWAY
Practice Address - Street 2:SUITE 300
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2583
Practice Address - Country:US
Practice Address - Phone:757-825-2500
Practice Address - Fax:757-825-2521
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048019207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA235056OtherANTHEM
VA006502415Medicaid
VA235056OtherANTHEM
VA006502415Medicaid
VAF32449Medicare UPIN