Provider Demographics
NPI:1134103450
Name:SANTORUFO, MILDRED JOANN (DO)
Entity Type:Individual
Prefix:DR
First Name:MILDRED
Middle Name:JOANN
Last Name:SANTORUFO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 SHILOH RD NW STE 2051
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-7199
Mailing Address - Country:US
Mailing Address - Phone:678-737-4863
Mailing Address - Fax:706-222-4016
Practice Address - Street 1:1275 SHILOH RD NW STE 2051
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7199
Practice Address - Country:US
Practice Address - Phone:678-737-4863
Practice Address - Fax:706-222-4016
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2022-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054935207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89066VFMedicaid
26465621OtherTRICARE SOUTH
TN3307791Medicaid
GA197568594BMedicaid
P00040221OtherRAILROAD MEDICARE
GAP00927672OtherRAILROAD MEDICARE
TN3307791Medicaid
TN3307791Medicaid