Healthcare Provider Details

I. General information

NPI: 1356601793
Provider Name (Legal Business Name): VIVIANA MARCELA FAJARDO MARTINEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIVIANA MARCELA FAJARDO MD

II. Dates (important events)

Enumeration Date: 05/19/2012
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE
LOS ANGELES CA
90095-3328
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-0867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number136292
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: