Healthcare Provider Details

I. General information

NPI: 1275519332
Provider Name (Legal Business Name): ALBERTO DOMINGUEZ VENTURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE SUITE 306
ALBUQUERQUE NM
87106-4917
US

IV. Provider business mailing address

4101 INDIAN SCHOOL RD NE STE 110
ALBUQUERQUE NM
87110-3991
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-1000
  • Fax: 505-563-1010
Mailing address:
  • Phone: 505-727-7096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36052
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number46968
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2011-0499
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: