Healthcare Provider Details

I. General information

NPI: 1336447531
Provider Name (Legal Business Name): MICHELLE B FAJARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 KELLOGG AVE
CORONA CA
92879
US

IV. Provider business mailing address

2055 KELLOGG AVE
CORONA CA
92879-3111
US

V. Phone/Fax

Practice location:
  • Phone: 866-984-7483
  • Fax:
Mailing address:
  • Phone: 951-965-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA116012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: