MEDICARE: DR. BRYAN L. DALTON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2780	OK

General Provider Information

NPI Number	:	1386647428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRYAN L. DALTON D.O.

Provider Business Mailing Address
First Line	:	3100 S ELM PL
Second Line	:	STE A
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7950
Country	:	US
Telephone Number	:	918-455-7777
Fax Number	:	918-455-8105

Provider Business Practice Location Address
First Line	:	3100 S ELM PL
Second Line	:	STE A
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7950
Country	:	US
Telephone Number	:	918-455-7777
Fax Number	:	918-455-8105

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	04/18/2008

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