Healthcare Provider Details

I. General information

NPI: 1861654857
Provider Name (Legal Business Name): DOMINIQUE SANCHEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 S MAIN ST
VIRGINIA IL
62691-1519
US

IV. Provider business mailing address

331 S MAIN ST
VIRGINIA IL
62691-1519
US

V. Phone/Fax

Practice location:
  • Phone: 217-452-3057
  • Fax: 217-452-7245
Mailing address:
  • Phone: 217-452-3057
  • Fax: 217-452-7245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036128630
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: