Basic Information
| Provider Information | |||||||||
| NPI: | 1760702237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEAN RIZKALLAH, MD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 FOURTH AVE. | ||||||||
| Address2: | STE. 408 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 FOURTH AVE. | ||||||||
| Address2: | STE 408 | ||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919104430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196911990 | ||||||||
| FaxNumber: | 6196915977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | RIZKALLAH | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
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| 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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1003800368 | 05 | CA | MEDICAID |