Provider Demographics
NPI:1245222033
Name:NISSAN, GEORGE (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:NISSAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 N HALSTED ST STE 501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-2615
Mailing Address - Country:US
Mailing Address - Phone:773-388-6390
Mailing Address - Fax:312-867-7101
Practice Address - Street 1:1460 N HALSTED ST STE 501
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-2615
Practice Address - Country:US
Practice Address - Phone:773-388-6390
Practice Address - Fax:312-867-7101
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0459207R00000X
IL36-108447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1500928-04Medicaid
TX1500928-05Medicaid
TXH57631Medicare UPIN
TXTXB139272Medicare PIN
TX1500928-04Medicaid
ILL97527Medicare PIN