Healthcare Provider Details

I. General information

NPI: 1710068978
Provider Name (Legal Business Name): MONA M RISKALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MONA M RISKALLA MD

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-4598
  • Fax: 612-626-6905
Mailing address:
  • Phone: 612-626-4598
  • Fax: 612-626-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number48674
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number48674
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number48674
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: