| National Provider Identifier [NPI]: | 1588764724 |
| Last Name Of The Provider | DOMOTO |
| First Name Of The Provider | DOUGLASS |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | M.D., J.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2606 CLARK AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | SAINT LOUIS |
| Zip Code Of The Provider | 631032502 |
| State Code Of The Provider | MO |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nephrology |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 781 |
| Number Of Medicare Beneficiaries | 180 |
| Total Submitted Charge Amount | 239345 |
| Total Medicare Allowed Amount | 156550.17 |
| Total Medicare Payment Amount | 122069.51 |
| Total Medicare Standardized Payment Amount | 123867.37 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 14 |
| Number Of Medical Services | 781 |
| Number Of Medicare Beneficiaries With Medical Services | 180 |
| Total Medical Submitted Charge Amount | 239345 |
| Total Medical Medicare Allowed Amount | 156550.17 |
| Total Medical Medicare Payment Amount | 122069.51 |
| Total Medical Medicare Standardized Payment Amount | 123867.37 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 41 |
| Number Of Beneficiaries Age 65 to 74 | 58 |
| Number Of Beneficiaries Age 75 to 84 | 63 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 95 |
| Number Of Male Beneficiaries | 85 |
| Number Of Non Hispanic White Beneficiaries | 149 |
| 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 | 114 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 66 |
| Percent Of With Atrial Fibrillation | 16 |
| Percent Of With Alzheimers Disease or Dementia | 14 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 13 |
| Percent Of With Heart Failure | 49 |
| Percent Of With Chronic Kidney Disease | 75 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 30 |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 57 |
| Percent Of With Hyperlipidemia | 70 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 62 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 11 |
| Average HCC Risk Score Of Beneficiaries | 3.5298 |