Provider Demographics
NPI:1790780625
Name:DAYTON, MARK A (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:DAYTON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2317
Mailing Address - Country:US
Mailing Address - Phone:812-331-3405
Mailing Address - Fax:812-355-6538
Practice Address - Street 1:601 W 2ND ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2317
Practice Address - Country:US
Practice Address - Phone:812-331-3405
Practice Address - Fax:812-355-6538
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033747A207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200482850Medicaid
IN200482850Medicaid
INM400021631Medicare PIN
IN549210LLLMedicare ID - Type Unspecified