Healthcare Provider Details

I. General information

NPI: 1487944930
Provider Name (Legal Business Name): MATTHEW BRYAN MASTRODOMENICO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 MISSOURI AVE
SHREVEPORT LA
71109-4327
US

IV. Provider business mailing address

PO BOX 731280
DALLAS TX
75373-1280
US

V. Phone/Fax

Practice location:
  • Phone: 318-621-8820
  • Fax: 318-212-4189
Mailing address:
  • Phone: 318-841-9526
  • Fax: 318-841-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD.301728
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD37690
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: