Provider Demographics
NPI:1134784978
Name:RIZKALLA, JACOB (DPM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:RIZKALLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 OLD MILL RD APT 4
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:PA
Mailing Address - Zip Code:18938-1311
Mailing Address - Country:US
Mailing Address - Phone:906-367-0160
Mailing Address - Fax:
Practice Address - Street 1:163 TOWER CIR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3479
Practice Address - Country:US
Practice Address - Phone:606-679-7441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY286833213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program