Healthcare Provider Details

I. General information

NPI: 1578550950
Provider Name (Legal Business Name): MANUEL A FAJARDO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11042 72ND RD
FOREST HILLS NY
11375-8303
US

IV. Provider business mailing address

111 CHERRY VALLEY AVE APT 418
GARDEN CITY NY
11530-1573
US

V. Phone/Fax

Practice location:
  • Phone: 718-544-0918
  • Fax: 718-544-0919
Mailing address:
  • Phone: 516-741-4898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number136142
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: