1700951704 NPI number — MR. ROBERT J BACON JR. MD

Table of content: DR. NONA T COLBURN M.D. (NPI 1043457690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700951704 NPI number — MR. ROBERT J BACON JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACON
Provider First Name:
ROBERT
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700951704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1919 NORTH LOOP W STE 224
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77008-1366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-655-9410
Provider Business Mailing Address Fax Number:
713-869-4506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 NORTH LOOP W STE 224
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77008-1366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-655-9410
Provider Business Practice Location Address Fax Number:
713-869-4506
Provider Enumeration Date:
11/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  F0861 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 137509904 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00117827 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 137509907 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 260034924 . This is a "RR MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".