Healthcare Provider Details

I. General information

NPI: 1255305520
Provider Name (Legal Business Name): NOEL R FAJARDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 S MARYLAND PKWY
LAS VEGAS NV
89119-7537
US

IV. Provider business mailing address

7315 S. PECOS ROAD STE. 101
LAS VEGAS NV
89120
US

V. Phone/Fax

Practice location:
  • Phone: 702-982-7240
  • Fax: 702-952-5444
Mailing address:
  • Phone: 702-982-7240
  • Fax: 702-952-5444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number44964
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number12053
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: