Provider Demographics
NPI:1396274551
Name:BACON, JOSHUA BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:BENJAMIN
Last Name:BACON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 123594 DEPT 3594
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:4345 NELSON RD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4183
Practice Address - Country:US
Practice Address - Phone:337-480-7900
Practice Address - Fax:337-602-6358
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA323354207Q00000X
MO2017016687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine