Healthcare Provider Details

I. General information

NPI: 1457615460
Provider Name (Legal Business Name): EMELYNN JOANNE FAJARDO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 ROCKLAND RD
WILMINGTON DE
19803-3607
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-651-4200
  • Fax: 302-651-5951
Mailing address:
  • Phone: 26-514-0003
  • Fax: 302-651-5951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberC2-0013079
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number25MB09117500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberOS019939
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: