Provider Demographics
NPI:1457791428
Name:BACON, SHOSHANA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SHOSHANA
Middle Name:
Last Name:BACON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1771 MADISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-364-2144
Mailing Address - Fax:732-364-3559
Practice Address - Street 1:1771 MADISON AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-364-2144
Practice Address - Fax:732-364-3559
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA09955000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program