Provider Demographics
NPI:1720183981
Name:BACON, JOHN WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WAYNE
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 1:300 STEAM PLANT RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3032
Mailing Address - Country:US
Mailing Address - Phone:615-452-7223
Mailing Address - Fax:615-452-3894
Practice Address - Street 1:300 STEAM PLANT RD
Practice Address - Street 2:SUITE 210
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-3032
Practice Address - Country:US
Practice Address - Phone:615-452-7223
Practice Address - Fax:615-452-3894
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000035633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376661Medicaid
TN3376661Medicaid
TN3870259Medicare ID - Type Unspecified