Healthcare Provider Details

I. General information

NPI: 1528043429
Provider Name (Legal Business Name): CARLOS DEL VALLE MONTES DOMINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

IV. Provider business mailing address

6739 W CACTUS RD
PEORIA AZ
85381-5311
US

V. Phone/Fax

Practice location:
  • Phone: 623-562-0015
  • Fax:
Mailing address:
  • Phone: 833-242-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA50991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number58738
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: