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: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 COMMUNITY PLZ
SULLIVAN MO
63080-1567
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: 636-556-9952
Mailing address:
  • Phone: 573-468-2020
  • Fax: 877-428-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number2002015836
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier315935700
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: