Provider Demographics
NPI:1942658497
Name:DOMINIQUE, MAYA JANAY (MD)
Entity Type:Individual
Prefix:DR
First Name:MAYA
Middle Name:JANAY
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-9230
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-5380
Practice Address - Street 1:6091 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2619
Practice Address - Country:US
Practice Address - Phone:219-763-8112
Practice Address - Fax:219-884-2547
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2020-07-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01083909A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology