1477628733 NPI number — DR. DAVID L MATTINGLY DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477628733 NPI number — DR. DAVID L MATTINGLY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATTINGLY
Provider First Name:
DAVID
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1477628733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 OLD YORK RD
Provider Second Line Business Mailing Address:
SUITE 222
Provider Business Mailing Address City Name:
JENKINTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-517-5050
Provider Business Mailing Address Fax Number:
215-517-4105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
81 OLD YORK ROAD
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
JENKINTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-517-5050
Provider Business Practice Location Address Fax Number:
215-517-4105
Provider Enumeration Date:
11/22/2006

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: 207Q00000X , with the licence number:  OS009360L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0722997000 . This is a "BLUE CROSS PERSONAL CHOIC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1743575 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17435750006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7123369 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 32328 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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