Individual
MATTHEW BRYAN MASTRODOMENICO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2915 MISSOURI AVE, SHREVEPORT, LA 71109-4327
(318) 621-8820
(318) 212-4189
Mailing address
PO BOX 731280, DALLAS, TX 75373-1280
(318) 841-9526
(318) 841-9551
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
MD.301728
LA
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
MD37690
SC
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
13776549
CAQH
LA
05
—
2420763
—
LA
Enumeration date
04/17/2011
Last updated
07/22/2016
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