Basic Information
| Provider Information | |||||||||
| NPI: | 1922146596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAJARDO | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MPH, MTMH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 BOATNER RD | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 307 BOATNER RD | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2007 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | ME142177 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology | 208D00000X | 0061102 | CO | N | Allopathic & Osteopathic Physicians | General Practice | 2083P0901X | 01061083A | IN | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.