Provider Demographics
NPI:1003816794
Name:BACON, STUART P (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:P
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7794 RHEA COUNTY HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-5981
Mailing Address - Country:US
Mailing Address - Phone:423-775-4261
Mailing Address - Fax:423-570-2008
Practice Address - Street 1:7794 RHEA COUNTY HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-5981
Practice Address - Country:US
Practice Address - Phone:423-775-4261
Practice Address - Fax:423-570-2008
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMD9006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3164361Medicaid
TN3164361Medicaid
TN3164361Medicare ID - Type Unspecified