Healthcare Provider Details

I. General information

NPI: 1972529360
Provider Name (Legal Business Name): MARK R. DILL O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 W LAKE ST
FORT COLLINS CO
80521-4213
US

IV. Provider business mailing address

2111 W LAKE ST
FORT COLLINS CO
80521-4213
US

V. Phone/Fax

Practice location:
  • Phone: 406-234-2911
  • Fax:
Mailing address:
  • Phone: 406-234-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3437
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0004010
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number076578
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2586
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number007460
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: