Provider Demographics
NPI:1578550950
Name:FAJARDO, MANUEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:A
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:111 CHERRY VALLEY AVE
Mailing Address - Street 2:APT 418
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-1573
Mailing Address - Country:US
Mailing Address - Phone:516-741-4898
Mailing Address - Fax:
Practice Address - Street 1:11042 72ND RD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-8303
Practice Address - Country:US
Practice Address - Phone:718-544-0918
Practice Address - Fax:718-544-0919
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2020-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY1361422086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E38221Medicare UPIN