Basic Information
| Provider Information | |||||||||
| NPI: | 1174841936 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEAN RIZKALLAH, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 FOUTH AVE | ||||||||
| Address2: | STE 407 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919100000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 FOUTH AVE | ||||||||
| Address2: | STE 407 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919100000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | RIZKALLAH | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6196911990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A93296 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1003800368 | 05 | CA | MEDICAID |