Healthcare Provider Details

I. General information

NPI: 1649360512
Provider Name (Legal Business Name): DAVID C. DOMINGUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNM DEPARTMENT OF EMERGENCY MEDICINE MSC10 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-5062
  • Fax: 505-272-6503
Mailing address:
  • Phone: 505-272-3120
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number89-183
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: