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General NPI Number Information
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NPI Number | 1104972298
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Entity Type | Organization
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Legal Business Name | CUMMING FAMILY PRACTICE
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 319 CANTON RD
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City | CUMMING
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State | GA
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Zip | 30040-2213
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Country | US
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Telephone | 770-886-8152
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Fax | 770-886-8153
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Provider Business Mailing Address
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Address Line | 319 CANTON RD
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City | CUMMING
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State | GA
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Zip | 30040-2213
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Country | US
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Telephone | 770-886-8152
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Fax | 770-886-8153
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Authorized Official
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Title or Position | OWNER
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Name | MANUEL M FAJARDO
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Credential | M.D.
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Telephone | 770-886-8152
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 011753
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License Number State | GA
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