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General NPI Number Information
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NPI Number | 1144617440
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Entity Type | Individual
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Provider Name | MR. CHRISTOPHER MAX DOMINGUEZ
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Gender | Male
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Dates
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Enumeration Date | 04/24/2015
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Last Update Date | 08/31/2021
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Provider Practice Location Address
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Address Line | 601 DR MARTIN LUTHER KING JR AVE NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-3619
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Country | US
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Telephone | 505-727-7090
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Fax | 505-727-7096
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Provider Business Mailing Address
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Address Line | 1 UNIVERSITY OF NEW MEXICO MSC 10-6000
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City | ALBUQUERQUE
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State | NM
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Zip | 87120
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Country | US
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Telephone | 505-272-6487
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Fax | 505-272-4156
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 1144617440
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD2021-0490
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License Number State | NM
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