Provider Demographics
NPI:1013919232
Name:ADAJAR, FUNDADOR L (MD)
Entity Type:Individual
Prefix:
First Name:FUNDADOR
Middle Name:L
Last Name:ADAJAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 N WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6514
Mailing Address - Country:US
Mailing Address - Phone:575-624-0400
Mailing Address - Fax:575-623-1702
Practice Address - Street 1:2890 N WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6514
Practice Address - Country:US
Practice Address - Phone:575-624-0400
Practice Address - Fax:575-623-1702
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0003207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96879360Medicaid
NM345531YTYCMedicare PIN
NM96879360Medicaid