Provider Demographics
NPI:1902967508
Name:BACON, ALFRED E III (MD)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:E
Last Name:BACON
Suffix:III
Gender:M
Credentials:MD
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Mailing Address - Street 1:78 OMEGA DR
Mailing Address - Street 2:BLDG C
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2064
Mailing Address - Country:US
Mailing Address - Phone:302-368-2883
Mailing Address - Fax:302-368-2892
Practice Address - Street 1:78 OMEGA DR
Practice Address - Street 2:BLDG C
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2064
Practice Address - Country:US
Practice Address - Phone:302-368-2883
Practice Address - Fax:302-368-2892
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2019-01-09
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Provider Licenses
StateLicense IDTaxonomies
DEC10002927207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000113601Medicaid
DE163451I75Medicare PIN
DEA16528Medicare UPIN