Provider Demographics
NPI:1285619973
Name:FAJARDO, MARIO ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:ENRIQUE
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 HOLLY CREEK PL
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-1550
Mailing Address - Country:US
Mailing Address - Phone:925-825-5905
Mailing Address - Fax:925-825-5906
Practice Address - Street 1:COMMANDANT US COAST GUARD CG-1122
Practice Address - Street 2:2100 SECOND ST. SW
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20593-0001
Practice Address - Country:US
Practice Address - Phone:202-267-0801
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143895-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine