Basic Information
| Provider Information | |||||||||
| NPI: | 1154818821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DALTON | ||||||||
| MiddleName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 N RIDGEWAY DR | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760334115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175564800 | ||||||||
| FaxNumber: | 2149475425 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N RIDGEWAY DR | ||||||||
| Address2: | |||||||||
| City: | CLEBURNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760334115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175564800 | ||||||||
| FaxNumber: | 2149475425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1204821433 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.