Provider Demographics
NPI:1093102758
Name:BUCKNER, MONICA SHALISE' (MD)
Entity Type:Individual
Prefix:DR
First Name:MONICA
Middle Name:SHALISE'
Last Name:BUCKNER
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 1:5124 S INDIANA AVE UNIT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-3428
Mailing Address - Country:US
Mailing Address - Phone:615-491-1419
Mailing Address - Fax:
Practice Address - Street 1:3473 S. MARTIN LUTHER KING DRIVE
Practice Address - Street 2:#494
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4108
Practice Address - Country:US
Practice Address - Phone:773-358-8295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-21
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036146924207QG0300X, 207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty