Healthcare Provider Details

I. General information

NPI: 1225145626
Provider Name (Legal Business Name): MAHER A REZKALLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 01/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W FERN AVE
REDLANDS CA
92373-5916
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-3311
  • Fax: 909-777-3873
Mailing address:
  • Phone: 909-335-6286
  • Fax: 909-245-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number3436
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC55000
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: