Healthcare Provider Details

I. General information

NPI: 1164719720
Provider Name (Legal Business Name): MONIKA AGATA SIEDLARZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14933 FOUNDERS XING
LOCKPORT IL
60491-6712
US

IV. Provider business mailing address

16200 GOLFVIEW DR
LOCKPORT IL
60441-4655
US

V. Phone/Fax

Practice location:
  • Phone: 708-778-3001
  • Fax:
Mailing address:
  • Phone: 708-778-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD169639
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.149439
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5006822027
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: