Provider Demographics
NPI:1962505750
Name:BACON, CARL WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:WILLIAM
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 121
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:801-812-5401
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181471-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107007443103OtherIHC
UT68078OtherPEHP
UT09-00096OtherUTAH HEALTHCARE
UT20045128OtherPALMETTO
UT870281028BACOtherEMIA
UT870281028000Medicaid
UT107007443103OtherIHC
UT09-00096OtherUTAH HEALTHCARE
UT107007443103OtherIHC
UT20045128OtherPALMETTO
UT0651550002Medicare NSC