Provider Demographics
NPI:1982602546
Name:MIMARI, GEORGE E (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:E
Last Name:MIMARI
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 1:8042 WURZBACH RD
Mailing Address - Street 2:STE 630
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3818
Mailing Address - Country:US
Mailing Address - Phone:210-614-5067
Mailing Address - Fax:210-593-5992
Practice Address - Street 1:8042 WURZBACH RD
Practice Address - Street 2:STE 630
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3818
Practice Address - Country:US
Practice Address - Phone:210-614-5067
Practice Address - Fax:210-593-5992
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE1063208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX809565801Medicaid
TX089565805Medicaid
TX089565805Medicaid
B24914Medicare UPIN