MEDICARE: DR. SEVERIANO FAJARDO SANJUAN JR. M.D.

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	MA34053	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891701595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SEVERIANO FAJARDO SANJUAN JR. M.D.

Provider Business Mailing Address
First Line	:	2040 MILLBURN AVE
Second Line	:	SUITE 302
City	:	MAPLEWOOD
State	:	NJ
Zip	:	07040-3726
Country	:	US
Telephone Number	:	973-762-0035
Fax Number	:	973-762-0402

Provider Business Practice Location Address
First Line	:	2040 MILLBURN AVE
Second Line	:	SUITE 302
City	:	MAPLEWOOD
State	:	NJ
Zip	:	07040-3726
Country	:	US
Telephone Number	:	973-762-0035
Fax Number	:	973-762-0402

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

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	12/12/2014

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