Provider Demographics
NPI:1811961469
Name:SANTILLI, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:SANTILLI
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 1:130 PRIMROSE LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-2307
Mailing Address - Country:US
Mailing Address - Phone:203-259-1055
Mailing Address - Fax:
Practice Address - Street 1:4 CORPORATE DR
Practice Address - Street 2:STE 295
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6240
Practice Address - Country:US
Practice Address - Phone:203-374-6103
Practice Address - Fax:203-374-1663
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001172626Medicaid