Healthcare Provider Details

I. General information

NPI: 1922146596
Provider Name (Legal Business Name): KEVIN ANTHONY FAJARDO MD, MPH, MTMH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2771 HEMLOCK ST STE 100
BREMERTON WA
98310-2689
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 360-360-2763
  • Fax: 360-707-7808
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0061102
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME142177
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number01061083A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD61301063
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: