Healthcare Provider Details

I. General information

NPI: 1033107982
Provider Name (Legal Business Name): LAURIE L FAJARDO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63110-1016
US

IV. Provider business mailing address

660 S EUCLID AVE CB 8131
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-7200
  • Fax: 314-747-4189
Mailing address:
  • Phone: 314-362-7200
  • Fax: 314-747-4189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2019036512
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: