Provider Demographics
NPI:1568117141
Name:FAJARDO, EMERY E
Entity Type:Individual
Prefix:
First Name:EMERY
Middle Name:E
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18403 KEYSTONE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-4813
Mailing Address - Country:US
Mailing Address - Phone:813-850-4343
Mailing Address - Fax:
Practice Address - Street 1:18403 KEYSTONE GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-4813
Practice Address - Country:US
Practice Address - Phone:813-850-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-13
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL07199600225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner