Provider Demographics
NPI:1578926002
Name:DOMENIK, CHRISTINE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DOMENIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-1629
Mailing Address - Country:US
Mailing Address - Phone:650-255-8366
Mailing Address - Fax:
Practice Address - Street 1:1080 LARSEN RD
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-2642
Practice Address - Country:US
Practice Address - Phone:650-255-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44378207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology