Healthcare Provider Details

I. General information

NPI: 1003236845
Provider Name (Legal Business Name): JESUS FAJARDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2014
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E BONITA AVE STE 101
POMONA CA
91767-1923
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-7437
  • Fax: 909-593-0318
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA138953
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: