Healthcare Provider Details

I. General information

NPI: 1750138939
Provider Name (Legal Business Name): ALEXANDRA BUCKWALTER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2024
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E 1ST ST
DIXON IL
61021-3116
US

IV. Provider business mailing address

403 E 1ST ST
DIXON IL
61021-3116
US

V. Phone/Fax

Practice location:
  • Phone: 815-285-5629
  • Fax: 815-285-5634
Mailing address:
  • Phone: 815-285-5629
  • Fax: 815-285-5634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036182233
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: