Provider Demographics
NPI:1174013932
Name:RENICK, DALTON MARK (DO)
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:MARK
Last Name:RENICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:4040 POSTAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6438
Practice Address - Country:US
Practice Address - Phone:540-772-4453
Practice Address - Fax:540-772-4717
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCLL51961208000000X
VA0102206530208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics