Provider Demographics
NPI:1144617440
Name:DOMINGUEZ, CHRISTOPHER MAX
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:MAX
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC 10-6000
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120
Mailing Address - Country:US
Mailing Address - Phone:505-272-6487
Mailing Address - Fax:505-272-4156
Practice Address - Street 1:601 DR MARTIN LUTHER KING JR AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3619
Practice Address - Country:US
Practice Address - Phone:505-727-7090
Practice Address - Fax:505-727-7096
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1144617440390200000X
NMMD2021-0490208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program