Provider Demographics
NPI:1215910757
Name:BACON, JEFFREY PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PAUL
Last Name:BACON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5442 LONGLEY LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3297
Mailing Address - Country:US
Mailing Address - Phone:775-770-7600
Mailing Address - Fax:775-770-7880
Practice Address - Street 1:5442 LONGLEY LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3297
Practice Address - Country:US
Practice Address - Phone:775-770-7600
Practice Address - Fax:775-770-7880
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8951207R00000X, 207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016729Medicaid
NV32135Medicare ID - Type Unspecified
NV002016729Medicaid