Provider Demographics
NPI:1093741969
Name:CRAIN, DOMINIQUE M (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:CRAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20375 W 151ST ST
Mailing Address - Street 2:451
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-5306
Mailing Address - Country:US
Mailing Address - Phone:913-829-0446
Mailing Address - Fax:
Practice Address - Street 1:20375 W 151ST ST
Practice Address - Street 2:451
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5306
Practice Address - Country:US
Practice Address - Phone:913-829-0446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33476207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200671820AMedicaid
KS30004194000001Medicaid