Provider Demographics
NPI:1538288311
Name:PISIMISIS, GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:PISIMISIS
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 1:71780 SAN JACINTO DR BLDG I
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-5516
Mailing Address - Country:US
Mailing Address - Phone:760-568-3461
Mailing Address - Fax:760-423-6273
Practice Address - Street 1:2720 N HARBOR BLVD STE 140
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2625
Practice Address - Country:US
Practice Address - Phone:657-566-8800
Practice Address - Fax:657-566-8810
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1753952086S0129X
390200000X
MN512332086S0129X
TXQ52502086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352728501Medicaid
MNENROLLEDMedicaid
TX453230YKQHMedicare PIN
TX352728501Medicaid