Healthcare Provider Details

I. General information

NPI: 1164152567
Provider Name (Legal Business Name): HORACIO GUILLERMO CARVAJAL DOMINGUEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MARIO CAPECCHI DR RM 4S100
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

30 N MARIO CAPECCHI DR RM 4S100
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-6803
  • Fax:
Mailing address:
  • Phone: 801-581-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14271822-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: