Provider Demographics
NPI:1821335670
Name:FAJARDO, EDGAR (LMT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 SW 8TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-2800
Mailing Address - Country:US
Mailing Address - Phone:305-858-8845
Mailing Address - Fax:305-858-8840
Practice Address - Street 1:426 SW 8TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-2800
Practice Address - Country:US
Practice Address - Phone:305-858-8845
Practice Address - Fax:305-858-8840
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA43850172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist