Healthcare Provider Details

I. General information

NPI: 1992795876
Provider Name (Legal Business Name): JORGE B PISARELLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FAIRVIEW PARK DR
DUBLIN GA
31021-2501
US

IV. Provider business mailing address

PO BOX 371
WRIGHTSVILLE GA
31096-0371
US

V. Phone/Fax

Practice location:
  • Phone: 478-864-3448
  • Fax: 478-864-1288
Mailing address:
  • Phone: 478-864-3448
  • Fax: 478-864-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberMD027109E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58914
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: