Provider Demographics
NPI:1023377579
Name:RIZKALLA, JESSE (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:RIZKALLA
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 1:116 LEAH CRES
Mailing Address - Street 2:
Mailing Address - City:THORNHILL
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:L4J 8C3
Mailing Address - Country:UG
Mailing Address - Phone:862-237-0726
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3011
Practice Address - Country:US
Practice Address - Phone:585-922-5067
Practice Address - Fax:585-922-2908
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303687208M00000X
GA74315207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program