Healthcare Provider Details

I. General information

NPI: 1336226463
Provider Name (Legal Business Name): GIL V FAJARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 60TH ST
WEST NEW YORK NJ
07093
US

IV. Provider business mailing address

47 RAMBLING DRIVE
SCOTCH PLAINS NJ
07076
US

V. Phone/Fax

Practice location:
  • Phone: 201-453-8777
  • Fax: 201-453-8804
Mailing address:
  • Phone: 201-453-8777
  • Fax: 201-453-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA62055
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: