1972692697 NPI number — LAURA P MATTINGLY PA

Table of content: LAURA P MATTINGLY PA (NPI 1972692697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972692697 NPI number — LAURA P MATTINGLY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTINGLY
Provider First Name:
LAURA
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972692697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99335
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76199-0335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-735-2363
Provider Business Mailing Address Fax Number:
817-735-2653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
855 MONTGOMERY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76107-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-735-2363
Provider Business Practice Location Address Fax Number:
817-735-2653
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA03908 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8245NN . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 183901102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y9490 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 183901101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 385175YS0Q , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: RAILROAD MEDICARE . This is a "P01447517" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 183901104 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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