Provider Demographics
NPI:1780680868
Name:DALTON, JEANINE (OD)
Entity type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:
Last Name:DALTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JEANINE
Other - Middle Name:
Other - Last Name:BOLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:230 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5904
Practice Address - Country:US
Practice Address - Phone:314-921-9377
Practice Address - Fax:314-830-2940
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02920152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314895400Medicaid
MO314895400Medicaid
U52484Medicare UPIN