Provider Demographics
NPI:1942291547
Name:DALTON, MARK ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:DALTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077-0280
Mailing Address - Country:US
Mailing Address - Phone:573-468-2020
Mailing Address - Fax:877-428-6732
Practice Address - Street 1:14 COMMUNITY PLZ
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-1567
Practice Address - Country:US
Practice Address - Phone:573-468-2020
Practice Address - Fax:636-556-9952
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002015836152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315935700Medicaid
MO315935700Medicaid