Provider Demographics
NPI:1548485816
Name:BACON, JEFFREY KYLE (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:KYLE
Last Name:BACON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8329 BRIMHALL RD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93312-2243
Mailing Address - Country:US
Mailing Address - Phone:661-695-8385
Mailing Address - Fax:661-679-6801
Practice Address - Street 1:8329 BRIMHALL RD
Practice Address - Street 2:SUITE 801
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2243
Practice Address - Country:US
Practice Address - Phone:661-695-8385
Practice Address - Fax:661-679-6801
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11715207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB206701OtherCMS NORIDIAN
CAGU585AOtherCMS NORIDIAN
CA0101340Medicaid
CA1265783948OtherGROUP NPI
DT5405OtherRR MEDICARE PTAN