Provider Demographics
NPI:1043268485
Name:NISTA, GEORGE M (OD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:M
Last Name:NISTA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2223
Mailing Address - Country:US
Mailing Address - Phone:773-233-4448
Mailing Address - Fax:773-233-4401
Practice Address - Street 1:3135 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2223
Practice Address - Country:US
Practice Address - Phone:773-233-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0460068861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362893564OtherNIPPON LIFE
IL362893564OtherWAUSAU INSURANCE
IL01633282OtherBCBS OF IL
IL362893564OtherAETNA
IL362893564OtherHUMANA CARE PLAN
IL0460068861Medicaid
IL362893564OtherGROUP ADMINISTRATORS
IL362893564OtherUNICARE
IL362893564OtherCONNECTICUT GENERAL
IL362893564OtherAMERICAN POSTAL WRKRS U
IL362893564OtherUNITED HEALTHCARE MIDWEST
IL362893564OtherGENERAL AMERICAN
IL362893564OtherPACIFIC LIFE
IL362893564OtherHUMANA
IL362893564OtherCIGNA
IL362893564OtherAMERICAN POSTAL WRKRS U
IL362893564OtherNIPPON LIFE
IL203314Medicare UPIN