Provider Demographics
NPI:1407050826
Name:DOMAN, TARA ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:ELIZABETH
Last Name:DOMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:ELIZABETH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:636 RAYMOND DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9789
Mailing Address - Country:US
Mailing Address - Phone:630-717-2300
Mailing Address - Fax:630-717-9638
Practice Address - Street 1:636 RAYMOND DR
Practice Address - Street 2:SUITE 205
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-9789
Practice Address - Country:US
Practice Address - Phone:630-717-2300
Practice Address - Fax:630-717-9638
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121608208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2215474OtherBCBS OF ILLINOIS
IL036121608Medicaid
IL036121608Medicaid