MEDICARE: DOMINIQUE DICAPUA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		IL

General Provider Information

NPI Number	:	1073052742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE DICAPUA

Provider Business Mailing Address
First Line	:	4703 N ANTHON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-4221
Country	:	US
Telephone Number	:	773-573-8330
Fax Number	:

Provider Business Practice Location Address
First Line	:	4703 N ANTHON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-4221
Country	:	US
Telephone Number	:	773-573-8330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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Directions to “ DOMINIQUE DICAPUA ” Practice Location

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