Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MD9006 | TN |
NPI | 1003816794 |
---|---|
Provider Name | Dr. Stuart P Bacon |
First Address | Dayton, TN 37321-5981 |
Second Address | Dayton, TN 37321-5981 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/07/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3164361 | (05) | TN |
B03050 | (02) |