Provider Demographics
NPI:1275617383
Name:FAJARDO, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:122 SO MICHIGAN AVE
Mailing Address - Street 2:#1413
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603
Mailing Address - Country:US
Mailing Address - Phone:312-922-6071
Mailing Address - Fax:312-922-5656
Practice Address - Street 1:122 SO MICHIGAN AVE
Practice Address - Street 2:#1413
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60603
Practice Address - Country:US
Practice Address - Phone:312-922-6071
Practice Address - Fax:312-922-5656
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036399902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21601162OtherBC BS
456400Medicare ID - Type Unspecified