Provider Demographics
NPI:1003236845
Name:FAJARDO, JESUS
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 E BONITA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1923
Mailing Address - Country:US
Mailing Address - Phone:909-593-7437
Mailing Address - Fax:909-593-0318
Practice Address - Street 1:255 E BONITA AVE STE 101
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1923
Practice Address - Country:US
Practice Address - Phone:909-593-7437
Practice Address - Fax:909-593-0318
Is Sole Proprietor?:No
Enumeration Date:2014-04-20
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138953207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery