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 1:1221 SIXTH ST STE 308
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2361
Mailing Address - Country:US
Mailing Address - Phone:231-935-5720
Mailing Address - Fax:231-935-5719
Practice Address - Street 1:1221 SIXTH ST STE 308
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2361
Practice Address - Country:US
Practice Address - Phone:231-935-5720
Practice Address - Fax:231-935-5719
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044523207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1777018-10Medicaid
MI1402410051OtherBCBS OF MICHIGAN
0240122Medicare ID - Type UnspecifiedMEDICARE NUMBER