Provider Demographics
NPI:1902283203
Name:J D FAJARDO DPM PC
Entity Type:Organization
Organization Name:J D FAJARDO DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-938-1368
Mailing Address - Street 1:1620 W HIGHWAY 287 BUSINESS
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-4706
Mailing Address - Country:US
Mailing Address - Phone:972-938-1368
Mailing Address - Fax:972-937-1354
Practice Address - Street 1:1620 W HIGHWAY 287 BUSINESS
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-4706
Practice Address - Country:US
Practice Address - Phone:972-938-1368
Practice Address - Fax:972-937-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0863213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic MedicineGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018835101Medicaid
TX0165800002Medicare NSC
TX00TN99Medicare PIN
TXT13217Medicare UPIN