Basic Information
| Provider Information | |||||||||
| NPI: | 1003800368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIZKALLAH | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 FOURTH AVENUE | ||||||||
| Address2: | STE. 408 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 FOURTH AVENUE | ||||||||
| Address2: | STE. 408 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 03/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A93296 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200430140 | 05 | IN | MEDICAID |