Provider Demographics
NPI:1245003706
Name:FAJARDO, DARYL
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:FAJARDO
Suffix:
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 1:16331 FAIRFIELD LN
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-9572
Mailing Address - Country:US
Mailing Address - Phone:269-815-2419
Mailing Address - Fax:
Practice Address - Street 1:7819 WAYNETOWNE BLVD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-2063
Practice Address - Country:US
Practice Address - Phone:937-938-1583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014807A225100000X
VACP032188T225100000X
OHCP025952T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist