Healthcare Provider Details

I. General information

NPI: 1235826462
Provider Name (Legal Business Name): DOMINIQUE MARIE MILSAP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

600 S PAULINA ST STE 403
CHICAGO IL
60612-3806
US

V. Phone/Fax

Practice location:
  • Phone: 888-352-7874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036180645
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: