Provider Demographics
NPI:1700998804
Name:FAJARDO, BLANCA S (MD)
Entity Type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:S
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STELLA
Other - Middle Name:
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1711 W TEMPLE ST
Mailing Address - Street 2:SUITE 6100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5421
Mailing Address - Country:US
Mailing Address - Phone:213-483-3991
Mailing Address - Fax:213-483-8287
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:SUITE 6100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-483-3991
Practice Address - Fax:213-483-8287
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87234207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00234341OtherRAILROAD MEDICARE
CA00A872340Medicaid
CAP00234341OtherRAILROAD MEDICARE
CAWA87234CMedicare ID - Type Unspecified
CA00A872340Medicaid
CAWA87234AMedicare ID - Type Unspecified
CAWA87234EMedicare ID - Type Unspecified