Provider Demographics
NPI:1023554748
Name:RIZKALLA, MARK (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:RIZKALLA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S TONOPAH DR STE 350
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4040
Mailing Address - Country:US
Mailing Address - Phone:702-384-6330
Mailing Address - Fax:702-384-2668
Practice Address - Street 1:1815 E LAKE MEAD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7189
Practice Address - Country:US
Practice Address - Phone:702-685-0440
Practice Address - Fax:702-974-6717
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV102355478Medicaid