Provider Demographics
NPI:1285764886
Name:DOMINGUEZ, KATHLEEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:CAVANAGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2529
Practice Address - Country:US
Practice Address - Phone:217-383-3100
Practice Address - Fax:217-383-4468
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI572642086S0120X
IL0361462802086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery