Healthcare Provider Details

I. General information

NPI: 1477682045
Provider Name (Legal Business Name): REBECA FAJARDO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECA FAJARDO MD

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 WEBB RD STE 203
TAMPA FL
33615-2865
US

IV. Provider business mailing address

6101 WEBB RD STE 203
TAMPA FL
33615-2865
US

V. Phone/Fax

Practice location:
  • Phone: 813-269-6426
  • Fax:
Mailing address:
  • Phone: 813-269-6426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME106105
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: