Provider Demographics
NPI:1336447531
Name:FAJARDO, MICHELLE B (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:B
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 KELLOGG AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3111
Mailing Address - Country:US
Mailing Address - Phone:951-965-3815
Mailing Address - Fax:
Practice Address - Street 1:2055 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:866-984-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine