Provider Demographics
NPI:1780675033
Name:DALTON, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:DALTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6445 HARRIS PKWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4138
Mailing Address - Country:US
Mailing Address - Phone:817-361-6900
Mailing Address - Fax:817-263-2918
Practice Address - Street 1:900 W MAGNOLIA AVE
Practice Address - Street 2:STE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-870-7300
Practice Address - Fax:817-332-8372
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2010-11-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXD7000207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
85Y012OtherBCBS
TX099326302Medicaid
7564001OtherAETNA
TX099326302Medicaid
85Y012OtherBCBS