| National Provider Identifier [NPI]: | 1396775334 |
| Last Name Of The Provider | DOMINGUEZ |
| First Name Of The Provider | CARMEN |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 320 NORTH CLYDE MORRIS BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | DAYTONA BEACH |
| Zip Code Of The Provider | 321142733 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Anesthesiology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 744 |
| Number Of Medicare Beneficiaries | 54 |
| Total Submitted Charge Amount | 47144.76 |
| Total Medicare Allowed Amount | 33069.47 |
| Total Medicare Payment Amount | 23795.12 |
| Total Medicare Standardized Payment Amount | 26588.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 387 |
| Number Of Medicare Beneficiaries With Drug Services | 22 |
| Total Drug Submitted ChargeAmount | 897.4 |
| Total Drug Medicare AllowedAmount | 639.47 |
| Total Drug Medicare PaymentAmount | 459.76 |
| Total Drug Medicare Standardized Payment Amount | 459.76 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 37 |
| Number Of Medical Services | 357 |
| Number Of Medicare Beneficiaries With Medical Services | 54 |
| Total Medical Submitted Charge Amount | 46247.36 |
| Total Medical Medicare Allowed Amount | 32430 |
| Total Medical Medicare Payment Amount | 23335.36 |
| Total Medical Medicare Standardized Payment Amount | 26128.44 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 17 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 33 |
| Number Of Male Beneficiaries | 21 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 39 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | 24 |
| Percent Of With Depression | 50 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 22 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.6044 |