Provider Demographics
NPI:1306088802
Name:DONNA L BACON MD PA
Entity type:Organization
Organization Name:DONNA L BACON MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-631-3693
Mailing Address - Street 1:1282 US HIGHWAY 1 STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2747
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101544100Medicaid
FLME71719OtherMEDICAL LIC
FL250973300Medicaid
FLBX214AMedicare PIN