Provider Demographics
NPI:1003800368
Name:RIZKALLAH, JEAN A (MD)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
Last Name:RIZKALLAH
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 1:450 FOURTH AVENUE
Mailing Address - Street 2:STE. 408
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4430
Mailing Address - Country:US
Mailing Address - Phone:619-691-1990
Mailing Address - Fax:619-691-5977
Practice Address - Street 1:450 FOURTH AVENUE
Practice Address - Street 2:STE. 408
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4430
Practice Address - Country:US
Practice Address - Phone:619-691-1990
Practice Address - Fax:619-691-5977
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200430140Medicaid
CAA93296Medicare PIN
INH88241Medicare UPIN
IN113150SSSSMedicare ID - Type UnspecifiedRIZKALLAH