Provider Demographics
NPI:1457324816
Name:DALTON, MARK RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:RAY
Last Name:DALTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SETON CENTER PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4107
Mailing Address - Country:US
Mailing Address - Phone:512-439-1000
Mailing Address - Fax:512-439-1081
Practice Address - Street 1:4700 SETON CENTER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4107
Practice Address - Country:US
Practice Address - Phone:512-439-1000
Practice Address - Fax:512-439-1081
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5499207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162846301Medicaid
TX8AJ073OtherBCBS OF TEXAS INDIVIDUAL #
TX8AJ073OtherBCBS OF TEXAS INDIVIDUAL #
TX8B2908Medicare PIN
TX5350980001Medicare NSC