Provider Demographics
NPI:1740559509
Name:BAJARO, GEMMA (PT)
Entity Type:Individual
Prefix:
First Name:GEMMA
Middle Name:
Last Name:BAJARO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 CANARIOS CT STE 110
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7877
Mailing Address - Country:US
Mailing Address - Phone:619-656-5102
Mailing Address - Fax:619-656-5143
Practice Address - Street 1:955 LANE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4525
Practice Address - Country:US
Practice Address - Phone:619-421-9521
Practice Address - Fax:619-421-9568
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GF659ZMedicare PIN