Provider Demographics
NPI:1255391132
Name:BACON, JEFFREY LANCE (DO)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LANCE
Last Name:BACON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3309
Mailing Address - Country:US
Mailing Address - Phone:480-461-2409
Mailing Address - Fax:
Practice Address - Street 1:615 FAIRHURST ST
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:CO
Practice Address - Zip Code:80751-4564
Practice Address - Country:US
Practice Address - Phone:970-521-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO38444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO95304789Medicaid
CA7428Medicare PIN
CO95304789Medicaid