Provider Demographics
NPI:1689882060
Name:JOSE FAJARDO
Entity Type:Organization
Organization Name:JOSE FAJARDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:372-398-1368
Mailing Address - Street 1:2439 FM 55
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-8936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1014 FERRIS AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2599
Practice Address - Country:US
Practice Address - Phone:972-938-1368
Practice Address - Fax:972-938-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
Not Answered213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty
Not Answered213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00TN99Medicare ID - Type Unspecified