Provider Demographics
NPI:1053986919
Name:FAYYAZ, RISHA
Entity type:Individual
Prefix:MS
First Name:RISHA
Middle Name:
Last Name:FAYYAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-5607
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5660
Practice Address - Fax:601-984-6870
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-06-15
Deactivation Date:2023-03-27
Deactivation Code:
Reactivation Date:2023-06-13
Provider Licenses
StateLicense IDTaxonomies
MST-4341207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine