Provider Demographics
NPI:1669446159
Name:PISANO, DOMENIC (DO)
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:
Last Name:PISANO
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 1:207 N BROAD ST
Mailing Address - Street 2:3RD FLR.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:215-462-7100
Mailing Address - Fax:215-463-3820
Practice Address - Street 1:196 W SPROUL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2045
Practice Address - Country:US
Practice Address - Phone:610-543-4000
Practice Address - Fax:610-543-4003
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS002998L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000751895Medicaid
PA074342GT6Medicare PIN