Provider Demographics
NPI:1215934476
Name:BACON, DONNA LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:LOUISE
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 1:7227 N US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT JOHN
Mailing Address - State:FL
Mailing Address - Zip Code:32927-5004
Mailing Address - Country:US
Mailing Address - Phone:321-631-3693
Mailing Address - Fax:321-631-7618
Practice Address - Street 1:1282 US HIGHWAY 1 STE 1
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2747
Practice Address - Country:US
Practice Address - Phone:321-631-3693
Practice Address - Fax:321-631-7618
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-02
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101544100Medicaid
FL250973300Medicaid
FL250973300Medicaid
32340AMedicare ID - Type Unspecified
FL32340VMedicare PIN