Provider Demographics
NPI:1023089133
Name:DIXON-GREVIOUS, DOLORES (MD)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:
Last Name:DIXON-GREVIOUS
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 1:2850 W 95TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2735
Mailing Address - Country:US
Mailing Address - Phone:708-389-2200
Mailing Address - Fax:708-389-6686
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-389-2200
Practice Address - Fax:708-389-6686
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100552207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100552Medicaid
IL210730/K13758Medicare ID - Type Unspecified
ILG80407Medicare UPIN