Provider Demographics
NPI:1356458012
Name:BACON, MELISSA M (DO)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:BACON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:NUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:113 MCRAE PT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6579
Mailing Address - Country:US
Mailing Address - Phone:507-250-7030
Mailing Address - Fax:
Practice Address - Street 1:113 MCRAE PT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6579
Practice Address - Country:US
Practice Address - Phone:507-250-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24598207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09336744Medicaid
MS09336744Medicaid
MN160003733Medicare PIN
MNI61187Medicare UPIN
MN160002607Medicare PIN