Basic Information
| Provider Information | |||||||||
| NPI: | 1144617440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | MAX | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC 10-6000 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052726487 | ||||||||
| FaxNumber: | 5052724156 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 DR MARTIN LUTHER KING JR AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057277090 | ||||||||
| FaxNumber: | 5057277096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2015 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 1144617440 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | MD2021-0490 | NM | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.