Provider Demographics
NPI:1861078206
Name:D'SOUZA, DOMINIQUE C (MD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:C
Last Name:D'SOUZA
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 1:3 SAINT ELIZABETH BLVD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1281
Mailing Address - Country:US
Mailing Address - Phone:618-233-5480
Mailing Address - Fax:
Practice Address - Street 1:3 SAINT ELIZABETH BLVD STE 4000
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1284
Practice Address - Country:US
Practice Address - Phone:618-233-7880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-23
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.169372207Q00000X
IL036169372207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist