Provider Demographics
NPI:1447417829
Name:FAJARDO, ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRES
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDRES
Other - Middle Name:
Other - Last Name:FAJARDO CARBONELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD
Practice Address - Street 2:MPC2 SUITE 3500
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1228
Practice Address - Country:US
Practice Address - Phone:317-962-0280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065981A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200980740Medicaid
IN815500263OtherMEDICARE PTAN
INP00911441OtherRAILROAD PTAN
INM400018709OtherMEDICARE PTAN