Provider Demographics
NPI:1689682791
Name:RIZKALLA, SAFWAT S (MD)
Entity Type:Individual
Prefix:
First Name:SAFWAT
Middle Name:S
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 1:5 HOLLAND STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2568
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:949-588-2199
Practice Address - Street 1:17161 GOLDENWEST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-5480
Practice Address - Country:US
Practice Address - Phone:714-373-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50231207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A502311Medicaid
CA00A502310OtherBLUE SHIELD
CA00A502310OtherBLUE SHIELD
CACG987YMedicare PIN
CACG987ZMedicare PIN
CAWA50231CMedicare PIN