Provider Demographics
NPI:1073967394
Name:RIZKALLA, MIRNA S (MD)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:S
Last Name:RIZKALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 SOUTH ST STE 404
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1508
Mailing Address - Country:US
Mailing Address - Phone:562-232-3910
Mailing Address - Fax:562-232-3204
Practice Address - Street 1:3650 SOUTH ST STE 404
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:562-232-3910
Practice Address - Fax:562-232-3204
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X207Q00000X
CAA161724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine