Provider Demographics
NPI:1346604725
Name:STEVENS, DOMINIQUE MAYA (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MAYA
Last Name:STEVENS
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 1:633 EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60208-0844
Mailing Address - Country:US
Mailing Address - Phone:847-491-5470
Mailing Address - Fax:847-491-5919
Practice Address - Street 1:633 EMERSON ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60208-0844
Practice Address - Country:US
Practice Address - Phone:847-491-5470
Practice Address - Fax:847-491-5919
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036154015207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program