Provider Demographics
NPI:1346443959
Name:FAJARDO, DANIEL ADRIAN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ADRIAN
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 1:3011 HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4264
Mailing Address - Country:US
Mailing Address - Phone:912-261-2669
Mailing Address - Fax:912-261-0561
Practice Address - Street 1:3011 HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4264
Practice Address - Country:US
Practice Address - Phone:912-261-2669
Practice Address - Fax:912-261-0561
Is Sole Proprietor?:No
Enumeration Date:2007-06-09
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062687207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
BP2-0021332OtherINSTITUTIONAL PERMIT
GAGRP3013Medicare PIN