Healthcare Provider Details

I. General information

NPI: 1528153467
Provider Name (Legal Business Name): BIENVENIDO FAJARDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 NAGLE AVE APT 1D
NEW YORK NY
10040
US

IV. Provider business mailing address

37 NAGLE AVE APT 1D
NEW YORK NY
10040-1483
US

V. Phone/Fax

Practice location:
  • Phone: 212-942-0808
  • Fax: 212-942-1553
Mailing address:
  • Phone: 212-942-0808
  • Fax: 212-942-1553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number163674
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number163674-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: