Healthcare Provider Details

I. General information

NPI: 1508818386
Provider Name (Legal Business Name): DOMINIC NEAL MASTRUSERIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 CHATHAM LANE SUITE 323
COLUMBUS OH
43221
US

IV. Provider business mailing address

941 CHATHAM LN SUITE 323
COLUMBUS OH
43221-2416
US

V. Phone/Fax

Practice location:
  • Phone: 614-442-6647
  • Fax: 614-442-6648
Mailing address:
  • Phone: 614-442-6647
  • Fax: 614-442-6648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35072392M
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: