Provider Demographics
NPI:1205935020
Name:RIZK, REGINA ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:ELIZABETH
Last Name:RIZK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NORTH POND DRIVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390
Mailing Address - Country:US
Mailing Address - Phone:248-669-2273
Mailing Address - Fax:248-926-8624
Practice Address - Street 1:100 NORTH POND DRIVE
Practice Address - Street 2:SUITE E
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-669-2273
Practice Address - Fax:248-926-8624
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPP052769208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0639787OtherBCBS
F70284OtherNAP
MI4292137Medicaid
0639787OtherBCBS