MEDICARE: DR. MARTA FAJARDO GORELIK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	G77143	CA

General Provider Information

NPI Number	:	1124200126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARTA FAJARDO GORELIK MD

Provider Business Mailing Address
First Line	:	PO BOX 1386
Second Line	:
City	:	SAN JUAN BAUTISTA
State	:	CA
Zip	:	95045-1386
Country	:	US
Telephone Number	:	831-623-4913
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 AHWAHNEE STREET
Second Line	:
City	:	SAN JUAN BAUTISTA
State	:	CA
Zip	:	95045-1386
Country	:	US
Telephone Number	:	831-623-4913
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2007
Last Update Date	:	07/21/2022

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