Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | A93296 | CA |
NPI | 1003800368 |
---|---|
Provider Name | Dr. Jean A. Rizkallah |
First Address | Chula Vista, CA 91910-4430 |
Second Address | Chula Vista, CA 91910-4430 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2005 |
Last Update Date | 30/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200430140 | (05) | IN |
H88241 | (02) | IN |