Provider Demographics
NPI:1063672145
Name:SURATI-TANTOD, MILLIE JAY (MD)
Entity type:Individual
Prefix:
First Name:MILLIE
Middle Name:JAY
Last Name:SURATI-TANTOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MILLIE
Other - Middle Name:
Other - Last Name:SURATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12291 WASHINGTON BLVD
Mailing Address - Street 2:SUITE #500
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90606-2500
Mailing Address - Country:US
Mailing Address - Phone:562-698-2541
Mailing Address - Fax:
Practice Address - Street 1:5355 WARNER AVE STE 102
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-6030
Practice Address - Country:US
Practice Address - Phone:714-477-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132755390200000X, 207Q00000X
NC2009-01996207Y00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916400Medicaid