Provider Demographics
NPI:1902943780
Name:FAJARDO, JAVIER E (MD)
Entity Type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:E
Last Name:FAJARDO
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 1:2023 VADALABENE DR
Mailing Address - Street 2:STE 200
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5636
Mailing Address - Country:US
Mailing Address - Phone:618-288-7408
Mailing Address - Fax:618-288-7418
Practice Address - Street 1:2419 W CORNERSTONE CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2529
Practice Address - Country:US
Practice Address - Phone:309-692-2025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117247207V00000X
IL036-117247207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology