Provider Demographics
NPI:1316926934
Name:LIKKI, SANTOSH R (MD)
Entity type:Individual
Prefix:
First Name:SANTOSH
Middle Name:R
Last Name:LIKKI
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 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:1184 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177
Practice Address - Country:US
Practice Address - Phone:937-382-1616
Practice Address - Fax:937-382-7877
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.078170208M00000X
KY38525207R00000X
OH35078170207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2203412Medicaid
KY64041635Medicaid
KY000000331954OtherANTHEM BCBS
IN200509220Medicaid
KY0614717Medicare PIN
KY0758311Medicare PIN
KY0654814Medicare PIN
KY64041635Medicaid
OH2203412Medicaid