Healthcare Provider Details

I. General information

NPI: 1700998804
Provider Name (Legal Business Name): BLANCA S FAJARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STELLA VARGAS

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 818-838-4587
  • Fax:
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA87234
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: