Provider Demographics
NPI:1477682045
Name:FAJARDO, REBECA (MD)
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECA
Other - Middle Name:
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6101 WEBB RD STE 203
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2865
Mailing Address - Country:US
Mailing Address - Phone:813-269-6426
Mailing Address - Fax:
Practice Address - Street 1:6101 WEBB RD STE 203
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2865
Practice Address - Country:US
Practice Address - Phone:813-269-6426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME106105OtherMEDICAL LICENSE