Provider Demographics
NPI:1568859742
Name:GARCIA FAJARDO, CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:GARCIA 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 1:720 PLEASANTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1306
Mailing Address - Country:US
Mailing Address - Phone:210-921-3800
Mailing Address - Fax:
Practice Address - Street 1:3520 S NEW BRAUNFELS AVE
Practice Address - Street 2:STE. 106A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1404
Practice Address - Country:US
Practice Address - Phone:210-921-3800
Practice Address - Fax:210-334-2851
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX447251YKQQMedicare PIN