Provider Demographics
NPI:1457342354
Name:BACON, WILLIAM GORDAN
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GORDAN
Last Name:BACON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 ELIZAVILLE AVE
Mailing Address - Street 2:PO BOX 426
Mailing Address - City:FLEMINGSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41041-9210
Mailing Address - Country:US
Mailing Address - Phone:606-849-3374
Mailing Address - Fax:606-845-0646
Practice Address - Street 1:935 ELIZAVILLE AVE
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041-9210
Practice Address - Country:US
Practice Address - Phone:606-849-3374
Practice Address - Fax:606-845-0646
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine