Provider Demographics
NPI:1154611986
Name:BACON, ANTHONY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WAYNE
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E RM 3C344
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-585-1618
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 3C344
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-585-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11275378-1205208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery