Healthcare Provider Details

I. General information

NPI: 1114286408
Provider Name (Legal Business Name): CECILE TEODORO FAJARDO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15525 POMERADO RD STE B1
POWAY CA
92064-2425
US

IV. Provider business mailing address

15525 POMERADO RD STE B1
POWAY CA
92064-2425
US

V. Phone/Fax

Practice location:
  • Phone: 858-487-8333
  • Fax: 858-487-0856
Mailing address:
  • Phone: 858-487-8333
  • Fax: 858-487-0856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A13143
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number20A13143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: