Provider Demographics
NPI:1144336769
Name:PISANO, CRESCENZO (MD)
Entity type:Individual
Prefix:
First Name:CRESCENZO
Middle Name:
Last Name:PISANO
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 1:1499 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3255
Mailing Address - Country:US
Mailing Address - Phone:310-831-9482
Mailing Address - Fax:310-831-1230
Practice Address - Street 1:1499 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3255
Practice Address - Country:US
Practice Address - Phone:310-831-9482
Practice Address - Fax:310-831-1230
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42081207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G420810Medicaid
A48805Medicare UPIN
CA00G420810Medicaid