Healthcare Provider Details

I. General information

NPI: 1770998775
Provider Name (Legal Business Name): RIYADH ZIHRAW AL-JAMMALY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MDG/SGXW 101 BODIN CIR
TRAVIS AFB CA
94535-1800
US

IV. Provider business mailing address

60 MDG/SGXW 101 BODIN CIR
TRAVIS AFB CA
94533-1800
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-5174
  • Fax:
Mailing address:
  • Phone: 707-423-5174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC1-0023966
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number56764
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: