Provider Demographics
NPI:1508818386
Name:MASTRUSERIO, DOMINIC NEAL (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:NEAL
Last Name:MASTRUSERIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:941 CHATHAM LN
Mailing Address - Street 2:SUITE 323
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2416
Mailing Address - Country:US
Mailing Address - Phone:614-442-6647
Mailing Address - Fax:614-442-6648
Practice Address - Street 1:941 CHATHAM LANE
Practice Address - Street 2:SUITE 323
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221
Practice Address - Country:US
Practice Address - Phone:614-442-6647
Practice Address - Fax:614-442-6648
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35072392M207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000130128OtherANTHEM
0300516OtherUHC
2309291OtherAETNA
OHMA0833063Medicare PIN
H34370Medicare UPIN
MA0833062Medicare ID - Type Unspecified