Provider Demographics
NPI:1043201346
Name:FAJARDO, ROMULO ABRANTES (MD)
Entity Type:Individual
Prefix:
First Name:ROMULO
Middle Name:ABRANTES
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:340 ANDERSON HOLLOW RD
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1100
Practice Address - Country:US
Practice Address - Phone:276-679-5880
Practice Address - Fax:276-679-9156
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
284730OtherANTHEM BCBS
VA5835810Medicaid
KY6400803000Medicaid
VAP00439704Medicare PIN
F43514Medicare UPIN
VA110007610Medicare PIN
284730OtherANTHEM BCBS