Provider Demographics
NPI:1891079455
Name:MA, FAJIE II
Entity Type:Individual
Prefix:
First Name:FAJIE
Middle Name:
Last Name:MA
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 MEADOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-1113
Mailing Address - Country:US
Mailing Address - Phone:408-636-6488
Mailing Address - Fax:209-288-5300
Practice Address - Street 1:123 S COMMERCE ST STE E
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2837
Practice Address - Country:US
Practice Address - Phone:209-910-9123
Practice Address - Fax:209-288-5300
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY944736208100000X
CAA129917208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation