Healthcare Provider Details

I. General information

NPI: 1174841936
Provider Name (Legal Business Name): JEAN RIZKALLAH, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 FOUTH AVE STE 407
CHULA VISTA CA
91910-0000
US

IV. Provider business mailing address

450 FOUTH AVE STE 407
CHULA VISTA CA
91910-0000
US

V. Phone/Fax

Practice location:
  • Phone: 619-691-1990
  • Fax: 619-691-5977
Mailing address:
  • Phone: 619-691-1990
  • Fax: 619-691-5977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA93296
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JEAN RIZKALLAH
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 619-691-1990