Healthcare Provider Details

I. General information

NPI: 1457077984
Provider Name (Legal Business Name): FAJARDO MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 CALLE ISABEL ANDREU E
FAJARDO PR
00738-4806
US

IV. Provider business mailing address

5A18 CALLE 5-2 URB. JARDINES DE MONTE BRISAS
FAJARDO PR
00738-3115
US

V. Phone/Fax

Practice location:
  • Phone: 787-663-6770
  • Fax:
Mailing address:
  • Phone: 330-979-7218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CARLY CARRION OLMEDA
Title or Position: PHYSICIAN
Credential: MD
Phone: 330-979-7218