Provider Demographics
NPI:1023223351
Name:FAJARDO, MILDRED THERESE (MD)
Entity Type:Individual
Prefix:
First Name:MILDRED THERESE
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146-0716
Mailing Address - Country:US
Mailing Address - Phone:724-342-5313
Mailing Address - Fax:724-342-5318
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-942-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4364952084P0800X, 2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024996330001Medicaid