Healthcare Provider Details

I. General information

NPI: 1407646060
Provider Name (Legal Business Name): RAZAN RIAD HALLAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11958 WEST BROAD STREET
RICHMOND VA
23233
US

IV. Provider business mailing address

1200 E BROAD ST
RICHMOND VA
23298-5025
US

V. Phone/Fax

Practice location:
  • Phone: 804-360-4669
  • Fax: 804-364-6521
Mailing address:
  • Phone: 804-828-9783
  • Fax: 804-828-5613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0116040450
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: