Provider Demographics
NPI:1710068978
Name:RISKALLA, MONA M (MD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:M
Last Name:RISKALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONA
Other - Middle Name:M
Other - Last Name:RISKALLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2450 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454-1450
Mailing Address - Country:US
Mailing Address - Phone:612-626-4598
Mailing Address - Fax:612-626-6905
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:612-626-4598
Practice Address - Fax:612-626-6905
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48674207RR0500X, 208000000X, 2080P0216X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN573606400Medicaid
H05946Medicare UPIN