Provider Demographics
NPI:1740397199
Name:CILLUFFO, JOHN MARINO (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARINO
Last Name:CILLUFFO
Suffix:
Gender:M
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 2070
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2070
Mailing Address - Country:US
Mailing Address - Phone:231-348-2811
Mailing Address - Fax:231-348-2836
Practice Address - Street 1:2202 MITCHELL PARK DR
Practice Address - Street 2:SUITE 6
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8897
Practice Address - Country:US
Practice Address - Phone:231-348-2811
Practice Address - Fax:231-348-2836
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044523207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1402410051OtherBCBS OF MICHIGAN
E37246Medicare UPIN
0240122Medicare ID - Type UnspecifiedMEDICARE NUMBER