Provider Demographics
NPI:1578576047
Name:BACON, CARRIE W (MD)
Entity Type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:W
Last Name:BACON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24471 CORTE DESCANSO
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6156
Mailing Address - Country:US
Mailing Address - Phone:714-851-5610
Mailing Address - Fax:
Practice Address - Street 1:31150 TEMECULA PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2921
Practice Address - Country:US
Practice Address - Phone:951-225-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABB8570904OtherDEA
CAI30307Medicare UPIN