Provider Demographics
NPI:1174841936
Name:JEAN RIZKALLAH, MD
Entity Type:Organization
Organization Name:JEAN RIZKALLAH, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RIZKALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-691-1990
Mailing Address - Street 1:450 FOUTH AVE
Mailing Address - Street 2:STE 407
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-0000
Mailing Address - Country:US
Mailing Address - Phone:619-691-1990
Mailing Address - Fax:619-691-5977
Practice Address - Street 1:450 FOUTH AVE
Practice Address - Street 2:STE 407
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-0000
Practice Address - Country:US
Practice Address - Phone:619-691-1990
Practice Address - Fax:619-691-5977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
CAA93296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1003800368Medicaid
CA1003800368Medicaid
CAA93296Medicare PIN