Healthcare Provider Details

I. General information

NPI: 1205918398
Provider Name (Legal Business Name): DIETRA DELAPLANE MILLARD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE WALGREEN 1505
EVANSTON IL
60201-1718
US

IV. Provider business mailing address

2650 RIDGE AVE WALGREEN 1505
EVANSTON IL
60201-1718
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2033
  • Fax: 847-570-0231
Mailing address:
  • Phone: 847-570-2033
  • Fax: 847-570-0231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036057096
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036057096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: