Basic Information
| Provider Information | |||||||||
| NPI: | 1316926934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIKKI | ||||||||
| FirstName: | SANTOSH | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PRESTIGE PL STE 550 | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453426115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377621310 | ||||||||
| FaxNumber: | 9375228068 | ||||||||
| Practice Location | |||||||||
| Address1: | 1184 W LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373821616 | ||||||||
| FaxNumber: | 9373827877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 38525 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35078170 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2203412 | 05 | OH | MEDICAID | 200509220 | 05 | IN | MEDICAID | 64041635 | 05 | KY | MEDICAID | 000000331954 | 01 | KY | ANTHEM BCBS | OTHER |