Matthew Bryan Mastrodomenico, M.D.

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

MD.301728 Issued in LA

Practice address

2915 Missouri Ave
Shreveport, LA 71109-4327

Phone

(318) 621-8820

Fax

(318) 212-4189

NPI assigned

Apr 17, 2011

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in LA, TX, NM3 enrollments

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 3

Specialty

Pathology

Education

Louisiana State University School of Medicine in Shreveport, 2011

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

The Delta Pathology Group LLCGroup PAC ID 4789639089, 28 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Willis Knighton Medical Center Hospital, Shreveport, LA, CCN 190111
• Fmol Health St Francis Hospital, Monroe, LA, CCN 190125

Merit-based Incentive Payment System (MIPS)

Final score

75 of 100Reported as individual

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• The Delta Pathology Group LLC

  • Anatomic Pathology & Clinical Pathology Physician
  • Shreveport, LA
  • NPI 1548258973

  NM

  Medicare reassignment Care Compare group NPD
• The Delta Pathology Group, L.L.C.

  • Clinical Medical Laboratory
  • Shreveport, LA
  • NPI 1649279910
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• St Francis Medical Center, Inc

  • General Acute Care Hospital
  • Monroe, LA
  • NPI 1295723229
  Care Compare affiliation
• Willis Knighton Medical Center, Inc.

  • General Acute Care Hospital
  • Bossier City, LA
  • NPI 1003968579
  Care Compare affiliation
• Willis Knighton Medical Center, Inc.

  • General Acute Care Hospital
  • Shreveport, LA
  • NPI 1124170691
  Care Compare affiliation
• Willis Knighton Medical Center, Inc.

  • General Acute Care Hospital
  • Shreveport, LA
  • NPI 1275685539
  Care Compare affiliation
• Willis Knighton Medical Center, Inc.

  • General Acute Care Hospital
  • Shreveport, LA
  • NPI 1568461572
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1302998400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1469145600000",
    "number": "1487944930",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 731280",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753731280",
            "telephone_number": "318-841-9526",
            "fax_number": "318-841-9551"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2915 MISSOURI AVE",
            "city": "SHREVEPORT",
            "state": "LA",
            "postal_code": "711094327",
            "telephone_number": "318-621-8820",
            "fax_number": "318-212-4189"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MASTRODOMENICO",
        "first_name": "MATTHEW",
        "middle_name": "BRYAN",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-04-17",
        "last_updated": "2016-07-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "LA",
            "license": "MD.301728",
            "primary": true
        },
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "SC",
            "license": "MD37690",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAQH",
            "identifier": "13776549",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2420763",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Stacey Ryder Massey, MD
• Herbert B Master, MD
• Monali Master
• Ryan Gary Master, MD
• Leonard Vincent Mastrodomenico, M.D.
• John Alexander Mata, M.D.
• Maya Matabele, MD
• Rebecca Matens
• Jolene Mateo, RN
• Walter Matheny II, APRN FNP-C

• Anatomic Pathology & Clinical Pathology Physician in Shreveport, LA
• Providers in Shreveport, LA by specialty
• Anatomic Pathology & Clinical Pathology Physician in Louisiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.