Provider Demographics
NPI:1659815793
Name:FAJARDO, RUDOLPH (PT)
Entity Type:Individual
Prefix:MR
First Name:RUDOLPH
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2131 HEARST AVE
Mailing Address - Street 2:APT 5
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1832
Mailing Address - Country:US
Mailing Address - Phone:212-663-4035
Mailing Address - Fax:
Practice Address - Street 1:2131 HEARST AVE
Practice Address - Street 2:# 5
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1832
Practice Address - Country:US
Practice Address - Phone:212-663-4035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32787225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist