Provider Demographics
NPI:1205192648
Name:SANTILUKKA, CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:SANTILUKKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 35TH ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-1932
Mailing Address - Country:US
Mailing Address - Phone:262-652-3500
Mailing Address - Fax:
Practice Address - Street 1:1020 35TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1932
Practice Address - Country:US
Practice Address - Phone:262-652-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61037-21207Q00000X
IAR-9001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100031358Medicaid