Provider Demographics
NPI:1164719720
Name:SIEDLARZ, MONIKA AGATA (MD)
Entity Type:Individual
Prefix:
First Name:MONIKA
Middle Name:AGATA
Last Name:SIEDLARZ
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 1:16200 GOLFVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-4655
Mailing Address - Country:US
Mailing Address - Phone:708-778-3001
Mailing Address - Fax:
Practice Address - Street 1:14933 FOUNDERS XING
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60491-6712
Practice Address - Country:US
Practice Address - Phone:708-778-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD169639208000000X
IL036.149439208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006822027Medicaid