Healthcare Provider Details

I. General information

NPI: 1275617383
Provider Name (Legal Business Name): ROBERT A FAJARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 SO MICHIGAN AVE #1413
CHICAGO IL
60603
US

IV. Provider business mailing address

122 SO MICHIGAN AVE #1413
CHICAGO IL
60603
US

V. Phone/Fax

Practice location:
  • Phone: 312-922-6071
  • Fax: 312-922-5656
Mailing address:
  • Phone: 312-922-6071
  • Fax: 312-922-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number03639990
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: