Healthcare Provider Details

I. General information

NPI: 1942291547
Provider Name (Legal Business Name): MARK ALAN DALTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 N CHURCH ST
SULLIVAN MO
63080-1568
US

IV. Provider business mailing address

PO BOX 280
SAINT CLAIR MO
63077-0280
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-2020
  • Fax: 877-428-6732
Mailing address:
  • Phone: 573-468-2020
  • Fax: 877-428-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2002015836
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: