Provider Demographics
NPI:1255391678
Name:MASTRODOMENICO, LEONARD VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:VINCENT
Last Name:MASTRODOMENICO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 DUNMORELAND CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-6101
Mailing Address - Country:US
Mailing Address - Phone:318-222-1149
Mailing Address - Fax:
Practice Address - Street 1:1800 BUCKNER ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4447
Practice Address - Country:US
Practice Address - Phone:318-222-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06900R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB89457Medicare UPIN