Provider Demographics
NPI:1780602417
Name:WILLIAMS, MONIQUE MARIE (MD)
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:
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:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-817-2000
Mailing Address - Fax:
Practice Address - Street 1:637 DUNN RD STE 102
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1747
Practice Address - Country:US
Practice Address - Phone:314-817-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002045377207RG0300X
TX44273207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17999Medicare UPIN
P00172051Medicare PIN
TX303668303Medicaid
921660183Medicare PIN
I17999Medicare UPIN
MO208776807Medicaid