Provider Demographics
NPI:1760476352
Name:FAJARDO, RENATO VERANO (MD)
Entity type:Individual
Prefix:
First Name:RENATO
Middle Name:VERANO
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 1:34616 11TH PL S STE 3
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8705
Mailing Address - Country:US
Mailing Address - Phone:253-874-5148
Mailing Address - Fax:253-874-4228
Practice Address - Street 1:34616 11TH PL S
Practice Address - Street 2:#3
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8705
Practice Address - Country:US
Practice Address - Phone:253-874-5148
Practice Address - Fax:253-874-4228
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA30962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
124708OtherLI
F60371Medicare UPIN
WAAB05874Medicare PIN