Provider Demographics
NPI:1598044745
Name:LARRAZALETA FAJARDO, CRISTINA MARIA (MD)
Entity type:Individual
Prefix:
First Name:CRISTINA
Middle Name:MARIA
Last Name:LARRAZALETA FAJARDO
Suffix:
Gender:F
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9220
Mailing Address - Fax:239-343-9231
Practice Address - Street 1:12600 CREEKSIDE LN
Practice Address - Street 2:SUITE 7
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3353
Practice Address - Country:US
Practice Address - Phone:239-343-9220
Practice Address - Fax:239-343-9231
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA263509207R00000X
FLME126357207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001679700Medicaid