Provider Demographics
NPI:1043565443
Name:RIZQALLAH, JASON J (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:J
Last Name:RIZQALLAH
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 1:47601 GRAND RIVER AVE # B136
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1233
Mailing Address - Country:US
Mailing Address - Phone:248-465-3940
Mailing Address - Fax:248-465-3941
Practice Address - Street 1:47601 GRAND RIVER AVE # B136
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374
Practice Address - Country:US
Practice Address - Phone:248-465-3940
Practice Address - Fax:248-465-3941
Is Sole Proprietor?:No
Enumeration Date:2012-07-21
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301101552208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery