Healthcare Provider Details

I. General information

NPI: 1588690200
Provider Name (Legal Business Name): YUSDENY FAJARDO V.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 NW 79TH AVE SUITE 322
DORAL FL
33166-6556
US

IV. Provider business mailing address

3900 NW 79TH AVE SUITE 322
DORAL FL
33166-6556
US

V. Phone/Fax

Practice location:
  • Phone: 305-471-9500
  • Fax: 305-471-9870
Mailing address:
  • Phone: 305-471-9500
  • Fax: 305-471-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME37781
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: